Provider Demographics
NPI:1790528768
Name:BLAKE, MICHAELA GRACE THANH (PA)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:GRACE THANH
Last Name:BLAKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 BRYANT WILLIAMS DR STE 102
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1139
Mailing Address - Country:US
Mailing Address - Phone:415-320-3249
Mailing Address - Fax:
Practice Address - Street 1:3000 BRYANT WILLIAMS DR STE 102
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1139
Practice Address - Country:US
Practice Address - Phone:541-274-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant