Provider Demographics
NPI:1073226817
Name:BIGEAGLE, BLAKE MONTANA
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:MONTANA
Last Name:BIGEAGLE
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 1:405 E EXCELSIOR AVE
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-4226
Mailing Address - Country:US
Mailing Address - Phone:918-559-9957
Mailing Address - Fax:
Practice Address - Street 1:405 E EXCELSIOR AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-4226
Practice Address - Country:US
Practice Address - Phone:918-559-9957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist