Provider Demographics
NPI:1306430848
Name:SQUIRES, BLAKE (PA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:SQUIRES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2405 CLEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-5775
Practice Address - Country:US
Practice Address - Phone:254-618-1888
Practice Address - Fax:254-519-5264
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE2568363A00000X
TXPA18017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant