Healthcare Provider Details

I. General information

NPI: 1174123541
Provider Name (Legal Business Name): WESTON BLAKE MILLS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 STATE ROAD 13 N STE 11-926
ST JOHNS FL
32259-8856
US

IV. Provider business mailing address

1820 STATE ROAD 13 N STE 11-926
ST JOHNS FL
32259-8856
US

V. Phone/Fax

Practice location:
  • Phone: 888-730-5220
  • Fax: 888-524-8166
Mailing address:
  • Phone: 888-730-5220
  • Fax: 888-524-8166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85.009903
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number030013
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number526
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7329
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA62842
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11779
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9724
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number110009096
License Number StateVA
# 9
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16952
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: