MEDICARE: VLORA BLAKE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110005151	VA

General Provider Information

NPI Number	:	1578918074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VLORA BLAKE PA-C

Provider Business Mailing Address
First Line	:	552 FORT EVANS RD
Second Line	:	SUITE 110
City	:	LEESBURG
State	:	VA
Zip	:	20176-3378
Country	:	US
Telephone Number	:	703-737-0197
Fax Number	:

Provider Business Practice Location Address
First Line	:	552 FORT EVANS RD
Second Line	:	SUITE 110
City	:	LEESBURG
State	:	VA
Zip	:	20176-3378
Country	:	US
Telephone Number	:	703-737-0197
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2016
Last Update Date	:	05/03/2016

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Directions to “ VLORA BLAKE PA-C” Practice Location

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