Provider Demographics
NPI:1497094262
Name:FLAKE, MATHEW REDGE
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:REDGE
Last Name:FLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1642
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-1642
Mailing Address - Country:US
Mailing Address - Phone:307-789-0664
Mailing Address - Fax:307-789-1902
Practice Address - Street 1:100 BEAR RIVER DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-2804
Practice Address - Country:US
Practice Address - Phone:307-789-0664
Practice Address - Fax:307-789-1902
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator