Provider Demographics
NPI:1629369004
Name:WAKE, RONALD STEVEN
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:STEVEN
Last Name:WAKE
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 1:206 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-3308
Mailing Address - Country:US
Mailing Address - Phone:307-347-6165
Mailing Address - Fax:307-347-6166
Practice Address - Street 1:206 S 7TH ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3308
Practice Address - Country:US
Practice Address - Phone:307-347-6165
Practice Address - Fax:307-347-6166
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106352903Medicaid
WY106352900Medicaid