Healthcare Provider Details

I. General information

NPI: 1447901665
Provider Name (Legal Business Name): ZACHARY IAN BLAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-667-2606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2726
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-15439
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: