Healthcare Provider Details

I. General information

NPI: 1134222458
Provider Name (Legal Business Name): KENT WILLIAM BLAKELY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 BALTIMORE DR
WILKES BARRE PA
18702-7900
US

IV. Provider business mailing address

14324 52ND AVE W UNIT B
EDMONDS WA
98026-3803
US

V. Phone/Fax

Practice location:
  • Phone: 800-275-6401
  • Fax:
Mailing address:
  • Phone: 425-951-0704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberG162755
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD042525L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD60640236
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMD042525L
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerSTATE LICENSE
# 2
IdentifierMD60640236
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE LICENSE
# 3
IdentifierMED-PHYS-COM-LIC-112
Identifier TypeOTHER
Identifier StateMT
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: