Basic Information
| Provider Information | |||||||||
| NPI: | 1326293523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKER | ||||||||
| FirstName: | SHELLEY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567000 | ||||||||
| FaxNumber: | 2152543289 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 OLD YORK RD | ||||||||
| Address2: | WILLOWCREST BLDG, 4TH FL | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154563953 | ||||||||
| FaxNumber: | 2154565948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2008 | ||||||||
| LastUpdateDate: | 12/02/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA053673 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.