Provider Demographics
NPI:1710028881
Name:BLAKE, KARSTEN J (PT)
Entity Type:Individual
Prefix:MR
First Name:KARSTEN
Middle Name:J
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3719 88TH ST NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-7228
Mailing Address - Country:US
Mailing Address - Phone:360-659-9621
Mailing Address - Fax:360-659-9621
Practice Address - Street 1:3719 88TH ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-7228
Practice Address - Country:US
Practice Address - Phone:360-659-9621
Practice Address - Fax:360-659-9621
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPT00006090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8332629Medicaid
WA8332629Medicaid