Provider Demographics
NPI:1588655682
Name:BLAKE, ANDRE ANTHONY (PA)
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:ANTHONY
Last Name:BLAKE
Suffix:
Gender:M
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 W FERN AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5916
Practice Address - Country:US
Practice Address - Phone:909-793-3311
Practice Address - Fax:909-335-4190
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16708363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ25944ZMedicare ID - Type UnspecifiedMEDICARE
CAZZZ374072Medicare ID - Type UnspecifiedMEDICARE
CA0PA167080Medicare UPIN
CAZZZ469352Medicare ID - Type UnspecifiedMEDICARE