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General NPI Number Information
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NPI Number | 1265083208
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Entity Type | Individual
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Provider Name | RYAN BLAKE FNP-BC
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Gender | Male
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Dates
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Enumeration Date | 09/20/2019
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Last Update Date | 09/20/2019
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Provider Practice Location Address
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Address Line | 3752 W 16TH ST
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City | CHICAGO
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State | IL
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Zip | 60623-2028
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Country | US
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Telephone | 773-762-2435
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Fax |
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Provider Business Mailing Address
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Address Line | 2613 W AUGUSTA BLVD APT 2R
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City | CHICAGO
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State | IL
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Zip | 60622-7451
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Country | US
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Telephone | 815-768-7404
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Fax |
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 209019763
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License Number State | IL
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