Provider Demographics
NPI:1275203127
Name:BLAKE, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:BLAKE
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 1:2668 E CITIZENS DR
Mailing Address - Street 2:STE 5
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4796
Mailing Address - Country:US
Mailing Address - Phone:479-442-7473
Mailing Address - Fax:479-442-7473
Practice Address - Street 1:2668 E CITIZENS DR STE 5
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4796
Practice Address - Country:US
Practice Address - Phone:479-595-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR49652251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic