Provider Demographics
NPI:1326293523
Name:BLAKER, SHELLEY (PA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:BLAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2421
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-3289
Practice Address - Street 1:5401 OLD YORK RD
Practice Address - Street 2:WILLOWCREST BLDG, 4TH FL
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-456-3953
Practice Address - Fax:215-456-5948
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053673363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232664784OtherTIN