Provider Demographics
NPI:1316394489
Name:BLAZE, ALEX
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:BLAZE
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 1:2311 S KENT DES MOINES RD APT A103
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-7083
Mailing Address - Country:US
Mailing Address - Phone:808-238-1783
Mailing Address - Fax:
Practice Address - Street 1:2311 S KENT DES MOINES RD APT A103
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-7083
Practice Address - Country:US
Practice Address - Phone:808-238-1783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60630103174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist