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General NPI Number Information
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NPI Number | 1043700214
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Entity Type | Individual
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Provider Name | REBECCA EVE O'DONNELL BLAKE PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/14/2018
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Last Update Date | 09/05/2023
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Provider Practice Location Address
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Address Line | 52 SECOND AVE
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City | WALTHAM
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State | MA
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Zip | 02451-1127
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Country | US
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Telephone | 781-487-6181
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Fax | 781-487-6826
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Provider Business Mailing Address
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Address Line | 52 SECOND AVE
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City | WALTHAM
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State | MA
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Zip | 02451-1127
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Country | US
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Telephone | 781-487-6181
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Fax | 781-487-6826
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA6527
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License Number State | MA
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