Individual
ANTWAIN WADE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
400 N STATE HIGHWAY 360 APT 1026, MANSFIELD, TX 76063-3588
(317) 413-5205
Mailing address
400 N STATE HIGHWAY 360 APT 1026, MANSFIELD, TX 76063-3588
(317) 413-5205
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
83-1958589
—
IN
Enumeration date
10/28/2021
Last updated
10/28/2021
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