Provider Demographics
NPI:1447284492
Name:WAKATAKE, EDWARD E (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:E
Last Name:WAKATAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 39TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2192
Mailing Address - Country:US
Mailing Address - Phone:253-435-3100
Mailing Address - Fax:
Practice Address - Street 1:1007 39TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2192
Practice Address - Country:US
Practice Address - Phone:253-435-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039599207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine