Basic Information
| Provider Information | |||||||||
| NPI: | 1760029862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JONATHAN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 CHESTNUT STREET | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137945700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 95 SARGENT STREET | ||||||||
| Address2: | |||||||||
| City: | BELCHERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010079881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133237212 | ||||||||
| FaxNumber: | 4139672524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2019 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA8403 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.