Basic Information
| Provider Information | |||||||||
| NPI: | 1487844395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAKE | ||||||||
| FirstName: | SONI | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 E EDNA AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135701752 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856072859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203647659 | ||||||||
| FaxNumber: | 5203648541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 40468 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208600000X | 40468 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | 40468 | AZ | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 362117 | 05 | AZ | MEDICAID |