Provider Demographics
NPI:1134477524
Name:LANDRY, BLAKE ANTHONY (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ANTHONY
Last Name:LANDRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 BILL CARRUTH PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3756
Mailing Address - Country:US
Mailing Address - Phone:770-422-1372
Mailing Address - Fax:678-363-5170
Practice Address - Street 1:148 BILL CARRUTH PKWY STE 100
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3756
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:678-363-5170
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALTA1743363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant