Basic Information
| Provider Information | |||||||||
| NPI: | 1104593102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706242420 | ||||||||
| FaxNumber: | 9706522928 | ||||||||
| Practice Location | |||||||||
| Address1: | 9480 BRIAR VILLAGE PT STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192783627 | ||||||||
| FaxNumber: | 7196232101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2021 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | APN.0995796-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.