Provider Demographics
NPI:1861502643
Name:HESS, BLAKE MARCUS (CSA)
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:MARCUS
Last Name:HESS
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12801 N 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1648
Mailing Address - Country:US
Mailing Address - Phone:602-677-7958
Mailing Address - Fax:
Practice Address - Street 1:12801 N 65TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1648
Practice Address - Country:US
Practice Address - Phone:602-677-7958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO06-173363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical