Healthcare Provider Details

I. General information

NPI: 1962438895
Provider Name (Legal Business Name): WADE HOLLINGSHEAD FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 N 100 W
BEAVER UT
84713-1690
US

IV. Provider business mailing address

PO BOX 1690
BEAVER UT
84713-1690
US

V. Phone/Fax

Practice location:
  • Phone: 435-438-7280
  • Fax: 435-438-7210
Mailing address:
  • Phone: 435-438-7280
  • Fax: 435-438-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4813074-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: