Provider Demographics
NPI:1801334362
Name:BLAKE-POPHAM, TRISHA LYNN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:TRISHA
Middle Name:LYNN
Last Name:BLAKE-POPHAM
Suffix:
Gender:F
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:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33601-1289
Mailing Address - Country:US
Mailing Address - Phone:813-277-8852
Mailing Address - Fax:
Practice Address - Street 1:409 BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2707
Practice Address - Country:US
Practice Address - Phone:813-844-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-05
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3772363AS0400X
FLPA9113106363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical