Provider Demographics
NPI:1730934050
Name:ANDERSON, WADE (ATC)
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31749 LA TIENDA RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4010
Mailing Address - Country:US
Mailing Address - Phone:818-575-9277
Mailing Address - Fax:
Practice Address - Street 1:31749 LA TIENDA RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-4010
Practice Address - Country:US
Practice Address - Phone:818-575-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer