Provider Demographics
NPI:1841234010
Name:BLAKE, TRENT ALTON (PA-C, ATC)
Entity Type:Individual
Prefix:MR
First Name:TRENT
Middle Name:ALTON
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1489 S HIGLEY RD
Mailing Address - Street 2:STE 101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4776
Mailing Address - Country:US
Mailing Address - Phone:480-457-8800
Mailing Address - Fax:480-457-8885
Practice Address - Street 1:1489 S HIGLEY RD
Practice Address - Street 2:STE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4776
Practice Address - Country:US
Practice Address - Phone:480-457-8800
Practice Address - Fax:480-457-8885
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ06612255A2300X
AZ4298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer