Provider Demographics
NPI:1588066021
Name:WADE, RICKY (FNP)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:WADE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 INDUSTRIAL AVE
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-2901
Mailing Address - Country:US
Mailing Address - Phone:817-444-3234
Mailing Address - Fax:817-444-3234
Practice Address - Street 1:141 INDUSTRIAL AVE
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-2901
Practice Address - Country:US
Practice Address - Phone:817-444-3234
Practice Address - Fax:817-444-3234
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX845182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX376438YKPWMedicare PIN