Provider Demographics
NPI:1497938096
Name:BLAKE, JOHN (ARNP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 W SWANN AVE
Mailing Address - Street 2:STE 600
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4039
Mailing Address - Country:US
Mailing Address - Phone:813-876-7073
Mailing Address - Fax:813-877-1277
Practice Address - Street 1:2605 W SWANN AVE
Practice Address - Street 2:STE 600
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4039
Practice Address - Country:US
Practice Address - Phone:813-876-7073
Practice Address - Fax:813-877-1277
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1158122363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner