Healthcare Provider Details

I. General information

NPI: 1366879801
Provider Name (Legal Business Name): LAURA MARIE WAKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

250 W PRATT ST STE 900
BALTIMORE MD
21201-6808
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-8667
  • Fax:
Mailing address:
  • Phone: 667-214-2507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberD0082866
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberD0082866
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: