Provider Demographics
NPI:1427727957
Name:YOUNG, BLAKE ALLEN (PA-C)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ALLEN
Last Name:YOUNG
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 1:1600 OXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2959
Mailing Address - Country:US
Mailing Address - Phone:580-603-3641
Mailing Address - Fax:
Practice Address - Street 1:3300 NW EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4418
Practice Address - Country:US
Practice Address - Phone:405-949-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4595363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant