Provider Demographics
NPI:1033354410
Name:BLAKE, KADIAN ALICIA
Entity Type:Individual
Prefix:MISS
First Name:KADIAN
Middle Name:ALICIA
Last Name:BLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 BURKE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3820
Mailing Address - Country:US
Mailing Address - Phone:917-569-7845
Mailing Address - Fax:
Practice Address - Street 1:1053 BURKE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3820
Practice Address - Country:US
Practice Address - Phone:917-569-7845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant