Healthcare Provider Details

I. General information

NPI: 1881716967
Provider Name (Legal Business Name): ROBERT C WAKEFIELD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 E SAGUARO ST
FLORENCE AZ
85132
US

IV. Provider business mailing address

10110 E HAY LOFT RD
FLORENCE AZ
85232-7441
US

V. Phone/Fax

Practice location:
  • Phone: 480-235-8545
  • Fax:
Mailing address:
  • Phone: 480-235-8545
  • Fax: 520-233-6114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3005
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3005
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: