Basic Information
| Provider Information | |||||||||
| NPI: | 1598266462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 HORSESHOE DR | ||||||||
| Address2: | |||||||||
| City: | WEST BOYLSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015831206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084501441 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1049 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011032114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137391100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2018 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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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 | 363A00000X | PA6440 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.