Basic Information
| Provider Information | |||||||||
| NPI: | 1164174801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1831 VICTORIA CIR | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553869688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9523566307 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7615 GOLDEN TRIANGLE DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127677222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2022 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | JZD123793269001 | 01 | BLUE CROSS BLUE SHIELD | OTHER |