Provider Demographics
NPI:1740235829
Name:BLAKE, RICHARD W (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 E WICKERSHAM WAY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-373-5950
Mailing Address - Fax:907-373-5954
Practice Address - Street 1:3600 E WICKERSHAM WAY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-373-5950
Practice Address - Fax:907-373-5954
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AK482363AM0700X
AKPADA482363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMB0593726OtherDEA NUMBER