Provider Demographics
NPI:1912348848
Name:WAKEFIELD, ELSA ALEXANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:ALEXANDRA
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELSA
Other - Middle Name:ALEXANDRA
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:409 S 2ND ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4300 LONDONDERRY RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5317
Practice Address - Country:US
Practice Address - Phone:717-231-8772
Practice Address - Fax:717-231-8435
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056196363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103152410Medicaid
PA335727Medicare PIN
PA103152410Medicaid