Healthcare Provider Details

I. General information

NPI: 1033925607
Provider Name (Legal Business Name): MR. BLAKE SPURLOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MOWRY AVE STE 222
FREMONT CA
94538-1605
US

IV. Provider business mailing address

2500 MOWRY AVE STE 222
FREMONT CA
94538-1605
US

V. Phone/Fax

Practice location:
  • Phone: 510-818-1160
  • Fax:
Mailing address:
  • Phone: 510-818-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66392
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: