Provider Demographics
NPI:1174162069
Name:ROBINSON, BLAKE AUSTIN (PA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:AUSTIN
Last Name:ROBINSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-541-7553
Mailing Address - Fax:239-343-4256
Practice Address - Street 1:2441 SURFSIDE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-3861
Practice Address - Country:US
Practice Address - Phone:239-541-7553
Practice Address - Fax:239-343-4256
Is Sole Proprietor?:No
Enumeration Date:2019-12-25
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114874363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL125232900Medicaid