Provider Demographics
NPI:1235307729
Name:BLAKELEY, MARK WADE (MSC, EMT-P)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WADE
Last Name:BLAKELEY
Suffix:
Gender:M
Credentials:MSC, EMT-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17155 HOLYOKE CT
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-9136
Mailing Address - Country:US
Mailing Address - Phone:303-601-5761
Mailing Address - Fax:
Practice Address - Street 1:17155 HOLYOKE COURT
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134
Practice Address - Country:US
Practice Address - Phone:303-601-5761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-18
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CO101YP2500X, 146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2791OtherPARAMEDIC CERTIFICATION