Provider Demographics
NPI:1194237974
Name:SMITH, WADE THOMAS (APRN)
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HEARTLAND DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2655
Mailing Address - Country:US
Mailing Address - Phone:304-256-1650
Mailing Address - Fax:863-304-8598
Practice Address - Street 1:100 HEARTLAND DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2655
Practice Address - Country:US
Practice Address - Phone:304-256-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9350693363LF0000X
FLAPRN9350693363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL823228283Medicaid