Provider Demographics
NPI:1104532795
Name:BLAKE, ALEXANDER DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:DANIEL
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4076 NEELY RD
Mailing Address - Street 2:RM 3C-404
Mailing Address - City:FT. WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4076 NEELY RD
Practice Address - Street 2:RM 3C-404
Practice Address - City:FT. WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-7440
Practice Address - Country:US
Practice Address - Phone:907-361-6028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-10-13
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant