MEDICARE: BLAKE ERNESTO CARRILLO 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	363AM0700X	Medical Physician Assistant	PA9107380	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588098040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE ERNESTO CARRILLO PA-C

Provider Business Mailing Address
First Line	:	173 KINGS WAY
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-1568
Country	:	US
Telephone Number	:	786-316-5665
Fax Number	:

Provider Business Practice Location Address
First Line	:	14150 SW 136TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-5506
Country	:	US
Telephone Number	:	786-204-4600
Fax Number	:

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

Provider Enumeration Date	:	09/02/2013
Last Update Date	:	04/28/2020

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