Traci Blake, PA
Physician Assistant in Englewood, NJ. Individual provider (NPI-1).
NPI number1922519271
StatusActive
Last updated in NPPESJul 18, 2022
Details
- NPI
- 1922519271
- Entity type
- Individual (NPI-1)
- Name
- Traci Blake
- Credential
- PA
- Sex
- Female
- Sole proprietor
- No
- Enumeration date
- Oct 13, 2017
- Certification date
- Jul 18, 2022
- Last updated
- Jul 18, 2022
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 363A00000X | Physician Assistant | 25mp00449500 | NJ | Yes |
| 363A00000X | Physician Assistant | 021388 | NY |
Practice location
401 S Van Brunt St Ste 3Englewood, NJ 07631-4600
Phone 201-569-2770 · Fax 201-569-1774
Mailing address
401 S Van Brunt St Ste 3Englewood, NJ 07631-4600
Phone 201-569-2770 · Fax 201-569-1774
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