Provider Demographics
NPI:1811578214
Name:BLAKE, TANNER JAMESON
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:JAMESON
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 CEDAR BAY CT APT 738
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-0203
Mailing Address - Country:US
Mailing Address - Phone:435-218-1198
Mailing Address - Fax:
Practice Address - Street 1:3501 CEDAR BAY CT APT 738
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-0203
Practice Address - Country:US
Practice Address - Phone:435-218-1198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant