Provider Demographics
NPI:1043532179
Name:BLANCO, LUIS A (PAC)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:A
Last Name:BLANCO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10606-2216
Mailing Address - Country:US
Mailing Address - Phone:917-572-6810
Mailing Address - Fax:
Practice Address - Street 1:10211 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2331
Practice Address - Country:US
Practice Address - Phone:718-898-1386
Practice Address - Fax:718-898-1093
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005075-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005075-1OtherLICENSE NO