Provider Demographics
NPI:1952551871
Name:BLAKE, ANDREA (DO)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 PINION DR
Mailing Address - Street 2:GENERAL SURGERY
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-2502
Mailing Address - Country:US
Mailing Address - Phone:719-333-5140
Mailing Address - Fax:719-333-5836
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:GENERAL SURGERY
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5140
Practice Address - Fax:719-333-5836
Is Sole Proprietor?:No
Enumeration Date:2008-09-28
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR0052469208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91585783Medicaid
CO309889YLB8Medicare PIN