Provider Demographics
NPI:1043432644
Name:BLENKE, ANITA T (PA-C)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:T
Last Name:BLENKE
Suffix:
Gender:F
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 1:1974 NE 178TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-2208
Mailing Address - Country:US
Mailing Address - Phone:305-947-6273
Mailing Address - Fax:
Practice Address - Street 1:1150 NW 14TH ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-2137
Practice Address - Country:US
Practice Address - Phone:305-243-6732
Practice Address - Fax:305-243-8015
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9101562363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant