Provider Demographics
NPI:1750390803
Name:BLAKE, DANIEL STEPHEN (SURGICAL FIRST ASST)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:STEPHEN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:SURGICAL FIRST ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 E ENROSE ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-5822
Mailing Address - Country:US
Mailing Address - Phone:480-220-8496
Mailing Address - Fax:
Practice Address - Street 1:1839 E ENROSE ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-5822
Practice Address - Country:US
Practice Address - Phone:480-220-8496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF01309363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical