Provider Demographics
NPI:1760029862
Name:BLAKE, PETER JONATHAN (PA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JONATHAN
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:151 WORCESTER RD
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:MA
Practice Address - Zip Code:01005-9002
Practice Address - Country:US
Practice Address - Phone:783-556-3219
Practice Address - Fax:978-355-6549
Is Sole Proprietor?:No
Enumeration Date:2019-12-08
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA8403363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical