Basic Information
| Provider Information | |||||||||
| NPI: | 1073163226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTOX | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3909 PALLAS WAY APT 3F | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272653631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364094310 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2019 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-09476 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-09476 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.