Provider Demographics
NPI:1346805454
Name:SHAHLAIE, BLAKE REZA (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:REZA
Last Name:SHAHLAIE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 194
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0194
Mailing Address - Country:US
Mailing Address - Phone:907-543-6149
Mailing Address - Fax:
Practice Address - Street 1:185 HOFFMAN ROAD
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:55995
Practice Address - Country:US
Practice Address - Phone:907-543-5158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK145511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9111989OtherFLORIDA DEPARTMENT OF HEALTH
AK145511OtherALASKA BOARD OF MEDICINE