Provider Demographics
NPI:1134653827
Name:BLAKEMORE, MATTHEW JEREMY (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JEREMY
Last Name:BLAKEMORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 DIAMOND CENTRE CT STE 1300
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4367
Mailing Address - Country:US
Mailing Address - Phone:239-344-9786
Mailing Address - Fax:239-344-9215
Practice Address - Street 1:6150 DIAMOND CENTRE CT STE 1300
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4367
Practice Address - Country:US
Practice Address - Phone:239-344-9786
Practice Address - Fax:239-344-9215
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110051363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant