Provider Demographics
NPI:1548260847
Name:WADE, THEODORE B (PA-C)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:B
Last Name:WADE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 MURPHY AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2023
Mailing Address - Country:US
Mailing Address - Phone:615-327-9543
Mailing Address - Fax:615-341-7583
Practice Address - Street 1:2011 MURPHY AVE
Practice Address - Street 2:STE 301
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2023
Practice Address - Country:US
Practice Address - Phone:615-327-9543
Practice Address - Fax:615-341-7583
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1429363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P80711Medicare UPIN
TN3665101Medicare PIN