Provider Demographics
NPI:1821599382
Name:MARTIN, BLAKE ANDREW (PA)
Entity Type:Individual
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First Name:BLAKE
Middle Name:ANDREW
Last Name:MARTIN
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Gender:M
Credentials:PA
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Mailing Address - Street 1:1411 E PRIMROSE ST STE C
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4377
Mailing Address - Country:US
Mailing Address - Phone:417-882-1207
Mailing Address - Fax:417-881-7268
Practice Address - Street 1:3801 S NATIONAL AVE STE 700
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-885-3888
Practice Address - Fax:471-520-5959
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2021-06-22
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Provider Licenses
StateLicense IDTaxonomies
MO2018004423363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical