Basic Information
| Provider Information | |||||||||
| NPI: | 1407237894 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAKE | ||||||||
| FirstName: | JOSHUA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 PROVIDENCE DR | ||||||||
| Address2: | ATTN: TRACI MITCHELL- ADMN | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767072261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543134200 | ||||||||
| FaxNumber: | 2543134326 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 PROVIDENCE DR | ||||||||
| Address2: | ATTN: TRACI MITCHELL- ADMN | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767072261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2543134200 | ||||||||
| FaxNumber: | 2543134326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2015 | ||||||||
| LastUpdateDate: | 01/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R0331 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | BP10054660 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.