Provider Demographics
NPI:1710348701
Name:BLAKE, ALEX (CSFA)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 YANKEE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-3500
Mailing Address - Country:US
Mailing Address - Phone:513-803-9600
Mailing Address - Fax:
Practice Address - Street 1:10743 S STATE ROUTE 133
Practice Address - Street 2:
Practice Address - City:BLANCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45107-9435
Practice Address - Country:US
Practice Address - Phone:937-728-9782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH157559363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical