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NPI Code Detail

MEDICARE: SOMER BLAKE

MEDICARE: SOMER BLAKE
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
1390200000XStudent in an Organized Health Care Education/Training Program
2363A00000XPhysician AssistantPA20264TX

General Provider Information

NPI Number : 1942058201
Entity Type Code : Individual
Provider Name (Legal Business Name) : SOMER BLAKE
Provider Business Mailing Address
First Line : 4560 LAKE HILL TRL
Second Line :
City : ELLENWOOD
State : GA
Zip : 30294-1693
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 720 WESTVIEW DR SW
Second Line :
City : ATLANTA
State : GA
Zip : 30310-1458
Country : US
Telephone Number : 404-756-1959
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/10/2024
Last Update Date : 06/04/2026

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Directions to “ SOMER BLAKE ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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