Provider Demographics
NPI:1285375071
Name:CHRISTENSEN, BLAKE WADE (DO)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:WADE
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MADISON PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2058
Mailing Address - Country:US
Mailing Address - Phone:208-390-1082
Mailing Address - Fax:
Practice Address - Street 1:320 W 10TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-6302
Practice Address - Country:US
Practice Address - Phone:509-221-5520
Practice Address - Fax:509-221-5521
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program