Provider Demographics
NPI:1043880834
Name:MEDLEY, BLAKE ALEXANDER
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ALEXANDER
Last Name:MEDLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 SHAVER DR
Mailing Address - Street 2:
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8552
Mailing Address - Country:US
Mailing Address - Phone:423-581-7040
Mailing Address - Fax:423-581-9563
Practice Address - Street 1:204 SHAVER DR
Practice Address - Street 2:
Practice Address - City:TALBOTT
Practice Address - State:TN
Practice Address - Zip Code:37877-8552
Practice Address - Country:US
Practice Address - Phone:423-581-7040
Practice Address - Fax:423-581-9563
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant