Provider Demographics
NPI:1932216975
Name:WAKE, KRISTINE M (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:M
Last Name:WAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE # MS 958
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:750 ROUND VALLEY DR STE 102
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7549
Practice Address - Country:US
Practice Address - Phone:435-655-0926
Practice Address - Fax:435-649-3748
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41975208000000X
UT12807093-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1932216975Medicaid
WI1932216975Medicaid
BW6123222OtherDEA NUMBER