Provider Demographics
NPI:1881716967
Name:WAKEFIELD, ROBERT C (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:WAKEFIELD
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 1:10110 E HAY LOFT RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85232-7441
Mailing Address - Country:US
Mailing Address - Phone:480-235-8545
Mailing Address - Fax:520-233-6114
Practice Address - Street 1:822 E SAGUARO ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132
Practice Address - Country:US
Practice Address - Phone:480-235-8545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3005207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ26574Medicare UPIN