Provider Demographics
NPI:1902180326
Name:BLAKE, REBECCA L (RPA-C)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:L
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:CHAUVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:258 HOOSICK ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2444
Practice Address - Country:US
Practice Address - Phone:518-272-0232
Practice Address - Fax:518-272-4083
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03788887Medicaid
NY140326000191OtherFIDELIS