Provider Demographics
NPI:1417409251
Name:HAWK, BLAKE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:
Last Name:HAWK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 ORCHARD PARK DR
Mailing Address - Street 2:
Mailing Address - City:WAKARUSA
Mailing Address - State:IN
Mailing Address - Zip Code:46573-9738
Mailing Address - Country:US
Mailing Address - Phone:574-354-7556
Mailing Address - Fax:
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-3193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28198864A367500000X
OHRN.400991367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered