Healthcare Provider Details

I. General information

NPI: 1255267548
Provider Name (Legal Business Name): BLAKE ANDREW NIZINSKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5662 SCREAMING EAGLE BLVD
FORT CAMPBELL KY
42223-5403
US

IV. Provider business mailing address

23 CAMELTOWN HILL RD
DANVILLE PA
17821-9589
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-7111
  • Fax:
Mailing address:
  • Phone: 570-492-2672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: