Provider Demographics
NPI:1346815750
Name:WADE, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5647 LIVE OAK ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-8015
Mailing Address - Country:US
Mailing Address - Phone:727-946-4089
Mailing Address - Fax:
Practice Address - Street 1:5647 LIVE OAK ST UNIT 1
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-8015
Practice Address - Country:US
Practice Address - Phone:727-946-4089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical