Provider Demographics
NPI:1124847512
Name:WADE, LESA (PT)
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12053 W SALTER DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85373-5667
Mailing Address - Country:US
Mailing Address - Phone:623-556-3626
Mailing Address - Fax:
Practice Address - Street 1:12053 W SALTER DR
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85373-5667
Practice Address - Country:US
Practice Address - Phone:623-556-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist