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General NPI Number Information
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NPI Number | 1518969377
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Entity Type | Individual
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Provider Name | MICHELLE PINTO WADE PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/11/2005
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 10325 SAN JOSE BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32257-6204
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Country | US
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Telephone | 904-717-1034
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Fax |
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Provider Business Mailing Address
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Address Line | 168 SHADOW RIDGE TRL
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City | PONTE VEDRA
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State | FL
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Zip | 32081-0068
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Country | US
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Telephone | 215-219-8182
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | PA9113264
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | MA051342
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA113264
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License Number State | FL
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