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General NPI Number Information
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NPI Number | 1295959310
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Entity Type | Organization
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Legal Business Name | BLAKE FAMILY MEDICINE PLLC
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 4704 MAIN ST
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City | SHALLOTTE
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State | NC
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Zip | 28470-1880
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Country | US
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Telephone | 910-754-4545
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Fax | 910-754-4794
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Provider Business Mailing Address
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Address Line | PO BOX 3206
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City | SHALLOTTE
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State | NC
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Zip | 28459-3206
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Country | US
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Telephone | 910-754-4545
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Fax | 910-754-4794
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Authorized Official
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Title or Position | OWNER
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Name | JOHN A BLAKE
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Credential | PA
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Telephone | 910-754-4545
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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 | 103290
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 103296
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 10868
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License Number State | NC
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