Provider Demographics
NPI:1427085596
Name:WADE, CAROL A (RN,CS,FNP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:WADE
Suffix:
Gender:F
Credentials:RN,CS,FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:21 E MAPLE ST
Practice Address - Street 2:SUITE A
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-4900
Practice Address - Country:US
Practice Address - Phone:208-788-3200
Practice Address - Fax:208-788-3386
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP185A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP01032142OtherMCRR
ID805065200Medicaid
IDP01032142OtherMCRR
IDQ20163Medicare UPIN