Provider Demographics
NPI:1053383554
Name:FORNANDER, WADE (MD)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:FORNANDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E H ST
Mailing Address - Street 2:
Mailing Address - City:MC COOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-3432
Mailing Address - Country:US
Mailing Address - Phone:308-344-4110
Mailing Address - Fax:308-344-8369
Practice Address - Street 1:4600 VALLEY RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4855
Practice Address - Country:US
Practice Address - Phone:402-483-4571
Practice Address - Fax:308-344-8369
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470748011-12Medicaid