Provider Demographics
NPI:1619670072
Name:GRIDER, BLAKE ANDREW
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:ANDREW
Last Name:GRIDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 FIRESTONE RD NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-3346
Mailing Address - Country:US
Mailing Address - Phone:330-813-8245
Mailing Address - Fax:
Practice Address - Street 1:1972 CLARK AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3929
Practice Address - Country:US
Practice Address - Phone:800-992-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant