MEDICARE: MR. TAYLOR MAX WADE FNP-C

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	363LF0000X	Family Nurse Practitioner	1-138196	AL
2	363L00000X	Nurse Practitioner	F01191470	AL

General Provider Information

NPI Number	:	1689139040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TAYLOR MAX WADE FNP-C

Provider Business Mailing Address
First Line	:	1505 PELHAM RD S STE 2
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-3707
Country	:	US
Telephone Number	:	256-435-7300
Fax Number	:	256-435-7305

Provider Business Practice Location Address
First Line	:	1505 PELHAM RD S STE 2
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-3707
Country	:	US
Telephone Number	:	256-435-7300
Fax Number	:	256-435-7305

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

Provider Enumeration Date	:	02/08/2019
Last Update Date	:	01/14/2021

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