Provider Demographics
NPI:1154967156
Name:CEDARLEAF, BLAKE HUNTER (PA-C)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:HUNTER
Last Name:CEDARLEAF
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16832 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:GRASSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55030-4506
Mailing Address - Country:US
Mailing Address - Phone:651-528-9173
Mailing Address - Fax:
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13252363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical