MEDICARE: PATRICE LYNN WAKEFIELD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	34692	MO

General Provider Information

NPI Number	:	1558538850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICE LYNN WAKEFIELD M.D.

Provider Business Mailing Address
First Line	:	514 DONNE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-3918
Country	:	US
Telephone Number	:	314-721-7329
Fax Number	:	314-725-2319

Provider Business Practice Location Address
First Line	:	514 DONNE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-3918
Country	:	US
Telephone Number	:	314-721-7329
Fax Number	:	314-725-2319

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2008
Last Update Date	:	05/15/2008

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