Provider Demographics
NPI:1780772749
Name:BLAKE, ROBERT F (MMS, PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:F
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1447 MEDICAL PARK BLVD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3164
Mailing Address - Country:US
Mailing Address - Phone:561-844-0120
Mailing Address - Fax:561-800-1074
Practice Address - Street 1:1447 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE #101
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3164
Practice Address - Country:US
Practice Address - Phone:561-844-0120
Practice Address - Fax:561-800-1074
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-02-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9103551363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC217ZMedicare PIN