Provider Demographics
NPI:1770282469
Name:WARREN, WADE (RD, LD)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:WARREN
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:
Practice Address - Street 1:2880 N TENAYA WAY STE 320
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0642
Practice Address - Country:US
Practice Address - Phone:702-862-8226
Practice Address - Fax:702-862-8227
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV40394-DI-1133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1770282469Medicaid
NV40394-DI-1OtherSTATE LICENSE