Provider Demographics
NPI:1538208533
Name:BLAKE, CAROL VANDERPOEL (PA-C)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:VANDERPOEL
Last Name:BLAKE
Suffix:
Gender:F
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 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-738-4334
Mailing Address - Fax:717-738-3289
Practice Address - Street 1:446 N READING RD
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-9802
Practice Address - Country:US
Practice Address - Phone:717-738-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA240558UFWOtherMEDICARE PTAN