Healthcare Provider Details

I. General information

NPI: 1285499293
Provider Name (Legal Business Name): BLAKE FEINGOLD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 CREEK CROSSING BLVD
HAINESPORT NJ
08036-2766
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 609-267-1004
  • Fax:
Mailing address:
  • Phone: 856-206-4795
  • Fax: 856-206-4796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00830800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: