Provider Demographics
NPI:1811676489
Name:BURK, BLAKE (CRNA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BURK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 E ELWOOD ST STE 500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-1978
Mailing Address - Country:US
Mailing Address - Phone:480-256-1518
Mailing Address - Fax:480-304-3446
Practice Address - Street 1:4605 E ELWOOD ST STE 500
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-1978
Practice Address - Country:US
Practice Address - Phone:480-256-1518
Practice Address - Fax:480-304-3446
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ301627367500000X
FLRN9494883163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN9494883OtherRN LICENSE
AZ301627OtherCRNA LICENSE