Provider Demographics
NPI:1619215738
Name:STAKEBAKE, ERIC F (MPAS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:F
Last Name:STAKEBAKE
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6500 N SOCRUM LOOP RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4179
Mailing Address - Country:US
Mailing Address - Phone:863-853-3331
Mailing Address - Fax:863-853-3337
Practice Address - Street 1:6500 N SOCRUM LOOP RD STE 200
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4179
Practice Address - Country:US
Practice Address - Phone:863-853-3331
Practice Address - Fax:863-853-3337
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112051207N00000X, 2084N0400X
UT2853911206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant