Basic Information
| Provider Information | |||||||||
| NPI: | 1043406036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | VERA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NE GATEWAY CT NE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044039100 | ||||||||
| FaxNumber: | 7044039104 | ||||||||
| Practice Location | |||||||||
| Address1: | 1090 NE GATEWAY CT NE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044039100 | ||||||||
| FaxNumber: | 7044039104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 07/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 2932 | NC | N | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | 736 | NC | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 232009B | 01 | NC | MEDICARE GROUP PTAN | OTHER | 3404200 | 05 | NC | MEDICAID |