Provider Demographics
NPI:1972380509
Name:TOPPER, BLAKE AUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:AUSTIN
Last Name:TOPPER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 VANDERBILT PKWY
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5815
Mailing Address - Country:US
Mailing Address - Phone:631-896-0527
Mailing Address - Fax:
Practice Address - Street 1:21 VANDERBILT PKWY
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5815
Practice Address - Country:US
Practice Address - Phone:631-896-0527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty