Healthcare Provider Details

I. General information

NPI: 1770527962
Provider Name (Legal Business Name): PATRICK BLAKE WEST IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS LOUISIANA SSBN 743 (BLUE) 2100 THRESHER AVE
SILVERDALE WA
98315-2100
US

IV. Provider business mailing address

50A FREEMAN PL
BREMERTON WA
98312-1846
US

V. Phone/Fax

Practice location:
  • Phone: 360-315-4206
  • Fax: 360-396-4742
Mailing address:
  • Phone: 360-373-4103
  • Fax: 360-396-4742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: