Provider Demographics
NPI:1104001551
Name:BLAKE, EUGENIA
Entity Type:Individual
Prefix:
First Name:EUGENIA
Middle Name:
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 1:1300 HOSPITAL DR
Mailing Address - Street 2:SUITE 270
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3261
Mailing Address - Country:US
Mailing Address - Phone:843-884-5133
Mailing Address - Fax:843-972-2360
Practice Address - Street 1:1300 HOSPITAL DR
Practice Address - Street 2:SUITE 270
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3261
Practice Address - Country:US
Practice Address - Phone:843-884-5133
Practice Address - Fax:843-972-2360
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3452367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife