Provider Demographics
NPI:1134227945
Name:HARRIS, WADE (MD)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E LOGAN ST
Mailing Address - Street 2:STE 201
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4882
Mailing Address - Country:US
Mailing Address - Phone:208-454-0567
Mailing Address - Fax:
Practice Address - Street 1:211 E LOGAN ST
Practice Address - Street 2:STE 201
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4882
Practice Address - Country:US
Practice Address - Phone:208-454-0567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTL-37922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDI72062Medicare UPIN
ID1135640Medicare PIN