Provider Demographics
NPI:1821155870
Name:BLAIZE, DAVID E (PA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:E
Last Name:BLAIZE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:345 SCHERMERHORN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1025
Mailing Address - Country:US
Mailing Address - Phone:718-403-3547
Mailing Address - Fax:718-858-0145
Practice Address - Street 1:233 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-4924
Practice Address - Country:US
Practice Address - Phone:718-826-5904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001810363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001810OtherLICENSE