Healthcare Provider Details

I. General information

NPI: 1417843277
Provider Name (Legal Business Name): BLAKE THOMAS BJORNSTAD PA-AA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 EAGLES LANDING PKWY
STOCKBRIDGE GA
30281-5085
US

IV. Provider business mailing address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1606
US

V. Phone/Fax

Practice location:
  • Phone: 678-604-1053
  • Fax:
Mailing address:
  • Phone: 404-851-8917
  • Fax: 404-303-3636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number13448
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: