Provider Demographics
NPI:1043700214
Name:BLAKE, REBECCA EVE O'DONNELL (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:EVE O'DONNELL
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:EVE
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:52 SECOND AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1127
Mailing Address - Country:US
Mailing Address - Phone:781-487-6181
Mailing Address - Fax:781-487-6826
Practice Address - Street 1:52 SECOND AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1127
Practice Address - Country:US
Practice Address - Phone:781-487-6181
Practice Address - Fax:781-487-6826
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6527363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant