Provider Demographics
NPI:1073165486
Name:BLAKESLEE, AMY NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:BLAKESLEE
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 1:9175 COUNTY ROAD 166
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-9544
Mailing Address - Country:US
Mailing Address - Phone:719-239-0562
Mailing Address - Fax:
Practice Address - Street 1:2115 STUART AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2269
Practice Address - Country:US
Practice Address - Phone:719-589-8082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006059363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant