Individual
BLAKE REZA SHAHLAIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
185 HOFFMAN ROAD, BETHEL, AK 55995
(907) 543-5158
Mailing address
PO BOX 194, BETHEL, AK 99559-0194
(907) 543-6149
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
145511
AK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
145511
ALASKA BOARD OF MEDICINE
AK
01
—
9111989
FLORIDA DEPARTMENT OF HEALTH
FL
Enumeration date
05/03/2019
Last updated
10/07/2019
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