Provider Demographics
NPI:1982190377
Name:STAKE, MATTHEW STEVEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEVEN
Last Name:STAKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16837 ROOSEVELT LN
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17361-1625
Mailing Address - Country:US
Mailing Address - Phone:717-576-5162
Mailing Address - Fax:
Practice Address - Street 1:250 FAME AVE STE 206-A
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-1587
Practice Address - Country:US
Practice Address - Phone:717-316-2248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059828363AM0700X, 363A00000X
PAOA004494363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103552557Medicaid
PA727045OtherPA