Provider Demographics
NPI:1750178190
Name:CHILDRESS, BLAKE (PA-C)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:M
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 1:10403 PARMER CIR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-5782
Mailing Address - Country:US
Mailing Address - Phone:317-363-5420
Mailing Address - Fax:
Practice Address - Street 1:6140 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-2538
Practice Address - Country:US
Practice Address - Phone:773-564-9206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-21
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
IL085.011277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty