Healthcare Provider Details

I. General information

NPI: 1295959310
Provider Name (Legal Business Name): BLAKE FAMILY MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4704 MAIN ST
SHALLOTTE NC
28470-1880
US

IV. Provider business mailing address

PO BOX 3206
SHALLOTTE NC
28459-3206
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-4545
  • Fax: 910-754-4794
Mailing address:
  • Phone: 910-754-4545
  • Fax: 910-754-4794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10868
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103290
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103296
License Number StateNC

VIII. Authorized Official

Name: JOHN A BLAKE
Title or Position: OWNER
Credential: PA
Phone: 910-754-4545