Provider Demographics
NPI:1013559178
Name:BLIDCHENKO, MAKSIM (ARNP)
Entity Type:Individual
Prefix:
First Name:MAKSIM
Middle Name:
Last Name:BLIDCHENKO
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9170
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-9170
Mailing Address - Country:US
Mailing Address - Phone:515-235-5000
Mailing Address - Fax:515-288-6713
Practice Address - Street 1:411 LAUREL ST STE A250
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3029
Practice Address - Country:US
Practice Address - Phone:515-235-5000
Practice Address - Fax:515-288-6713
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA156720363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner