Provider Demographics
NPI:1154412617
Name:FLAKE, BRENDA L (MD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:FLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:L
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 34036
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1036
Mailing Address - Country:US
Mailing Address - Phone:425-899-3292
Mailing Address - Fax:425-899-3269
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-899-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032577207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1094374Medicaid
WA1094374Medicaid
WAG8872198Medicare PIN
WAAB39157Medicare ID - Type Unspecified
WAG10591Medicare UPIN