Basic Information
| Provider Information | |||||||||
| NPI: | 1154486769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5590 KIETZKE LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895113019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753232080 | ||||||||
| FaxNumber: | 7753238216 | ||||||||
| Practice Location | |||||||||
| Address1: | 5590 KIETZKE LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895113019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753232080 | ||||||||
| FaxNumber: | 7756839404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 14407 | NV | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | A95206 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MD60071790 | WA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | A95206 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | MD60071790 | WA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | 14407 | NV | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.