=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881262707
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WADE FONTES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2021
-----------------------------------------------------
Last Update Date | 06/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1356 RIDDER PARK DR
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95131-2313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-465-8280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2466 S BASCOM AVE APT 5
-----------------------------------------------------
City | CAMPBELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95008-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-278-2682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------