Provider Demographics
NPI:1760946180
Name:JOECKEL, BLAKE GRAYSON (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:GRAYSON
Last Name:JOECKEL
Suffix:
Gender:M
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3677 GLENBARRY CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2605
Mailing Address - Country:US
Mailing Address - Phone:910-273-5150
Mailing Address - Fax:
Practice Address - Street 1:116 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-7604
Practice Address - Country:US
Practice Address - Phone:910-488-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine