Provider Demographics
NPI:1790528768
Name:BLAKE, MICHAELA GRACE THANH (PA-S)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:GRACE THANH
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6571 NE CHERRY DR APT 2216
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-7731
Mailing Address - Country:US
Mailing Address - Phone:415-320-3249
Mailing Address - Fax:
Practice Address - Street 1:705 SE BASELINE ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4244
Practice Address - Country:US
Practice Address - Phone:503-357-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program