Provider Demographics
NPI:1831088343
Name:SIDLECK, BLAKE EDWARD (PA)
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:EDWARD
Last Name:SIDLECK
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:5479 GLENRIDGE DR APT 4404
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1340
Mailing Address - Country:US
Mailing Address - Phone:484-951-3217
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE STE 1700
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2262
Practice Address - Country:US
Practice Address - Phone:484-951-3217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant