Provider Demographics
NPI:1578509238
Name:BLAKE, SHANNON (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BLAKE
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 1:229 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3243
Mailing Address - Country:US
Mailing Address - Phone:860-371-5335
Mailing Address - Fax:
Practice Address - Street 1:631 QUAKER LN S
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1026
Practice Address - Country:US
Practice Address - Phone:860-233-5133
Practice Address - Fax:860-232-6527
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant