Provider Demographics
NPI:1437880010
Name:NELSON, BLAKE A (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:A
Last Name:NELSON
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 1:6924 NE SANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5256
Mailing Address - Country:US
Mailing Address - Phone:503-300-4111
Mailing Address - Fax:503-954-2122
Practice Address - Street 1:2935 SW CEDAR HILLS BLVD
Practice Address - Street 2:STE 100
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1342
Practice Address - Country:US
Practice Address - Phone:503-300-4111
Practice Address - Fax:503-954-2122
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA217352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant