Provider Demographics
NPI:1679128672
Name:HANSON, BLAKE ALEXANDER (PA-C)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ALEXANDER
Last Name:HANSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S WHEELING AVE STE 900
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5647
Mailing Address - Country:US
Mailing Address - Phone:918-403-6284
Mailing Address - Fax:918-403-6323
Practice Address - Street 1:2000 S WHEELING AVE STE 900
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5647
Practice Address - Country:US
Practice Address - Phone:918-403-6284
Practice Address - Fax:918-403-6323
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant