Provider Demographics
NPI:1992315899
Name:WAKE, MORGAN BLAKE (PA-C)
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:BLAKE
Last Name:WAKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 FOUNDERS RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79706-2978
Mailing Address - Country:US
Mailing Address - Phone:432-302-0719
Mailing Address - Fax:
Practice Address - Street 1:4214 ANDREWS HWY STE 110
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-4864
Practice Address - Country:US
Practice Address - Phone:432-689-2491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15111363A00000X, 261QU0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program