Provider Demographics
NPI:1588098040
Name:CARRILLO, BLAKE ERNESTO (PA-C)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ERNESTO
Last Name:CARRILLO
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 1:173 KINGS WAY
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1568
Mailing Address - Country:US
Mailing Address - Phone:786-316-5665
Mailing Address - Fax:
Practice Address - Street 1:14150 SW 136TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5506
Practice Address - Country:US
Practice Address - Phone:786-204-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-02
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107380363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHP728YMedicare PIN