Healthcare Provider Details

I. General information

NPI: 1093451718
Provider Name (Legal Business Name): BLAKE ALLEN WOOD DNAP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1819
US

IV. Provider business mailing address

6225 N STATE HIGHWAY 161 STE 200
IRVING TX
75038-2241
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-1000
  • Fax:
Mailing address:
  • Phone: 214-687-0001
  • Fax: 972-518-2100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95117961
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number138804
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: