Healthcare Provider Details

I. General information

NPI: 1134814023
Provider Name (Legal Business Name): JESSE BLAIRE PMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NW MARTIN LUTHER KING JR AVE
OCALA FL
34475-5810
US

IV. Provider business mailing address

505 NW MARTIN LUTHER KING JR AVE
OCALA FL
34475-5810
US

V. Phone/Fax

Practice location:
  • Phone: 352-239-5585
  • Fax: 352-629-8507
Mailing address:
  • Phone: 352-239-5585
  • Fax: 352-629-8507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberEMT84124
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberPMD200769
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: