Provider Demographics
NPI:1144656794
Name:HART, BLAKE LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:LEIGH
Last Name:HART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BLAKE
Other - Middle Name:L
Other - Last Name:KICINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:575 COAL VALLEY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CLAIRTON
Mailing Address - State:PA
Mailing Address - Zip Code:15025-3770
Mailing Address - Country:US
Mailing Address - Phone:412-267-6600
Mailing Address - Fax:412-267-6281
Practice Address - Street 1:575 COAL VALLEY RD STE 300
Practice Address - Street 2:
Practice Address - City:CLAIRTON
Practice Address - State:PA
Practice Address - Zip Code:15025-3770
Practice Address - Country:US
Practice Address - Phone:412-267-6600
Practice Address - Fax:412-267-6281
Is Sole Proprietor?:No
Enumeration Date:2013-09-15
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103191160Medicaid
PA103191160Medicaid