Provider Demographics
NPI:1548916786
Name:BLAKE, JUDI ELLEN (PA-C)
Entity type:Individual
Prefix:
First Name:JUDI
Middle Name:ELLEN
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 1:2100 PFINGSTEN RD STE 3001
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1301
Mailing Address - Country:US
Mailing Address - Phone:847-657-5815
Mailing Address - Fax:847-657-3724
Practice Address - Street 1:2100 PFINGSTEN RD STE 3001
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1301
Practice Address - Country:US
Practice Address - Phone:847-657-5815
Practice Address - Fax:847-657-3724
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009438363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant