Healthcare Provider Details

I. General information

NPI: 1790480549
Provider Name (Legal Business Name): BLAKE ALLAN PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 MAIN ST STE 7230
BUFFALO NY
14203-1121
US

IV. Provider business mailing address

955 MAIN ST STE 7230
BUFFALO NY
14203-1121
US

V. Phone/Fax

Practice location:
  • Phone: 716-829-2012
  • Fax: 716-829-3999
Mailing address:
  • Phone: 716-829-2012
  • Fax: 716-829-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number343066
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: