MEDICARE: WADE HARRIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	TL-3792	ID

General Provider Information

NPI Number	:	1134227945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WADE HARRIS MD

Provider Business Mailing Address
First Line	:	211 E LOGAN ST
Second Line	:	STE 201
City	:	CALDWELL
State	:	ID
Zip	:	83605-4882
Country	:	US
Telephone Number	:	208-454-0567
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 E LOGAN ST
Second Line	:	STE 201
City	:	CALDWELL
State	:	ID
Zip	:	83605-4882
Country	:	US
Telephone Number	:	208-454-0567
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/08/2007

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