Healthcare Provider Details

I. General information

NPI: 1457997223
Provider Name (Legal Business Name): WADE YOUNT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PORTER DR
MIDDLEBURY VT
05753-8423
US

IV. Provider business mailing address

115 PORTER DR
MIDDLEBURY VT
05753-8423
US

V. Phone/Fax

Practice location:
  • Phone: 802-388-4100
  • Fax:
Mailing address:
  • Phone: 802-388-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055-0031548
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: