Provider Demographics
NPI:1083178867
Name:BLANCO, AUDY EMILIO
Entity Type:Individual
Prefix:
First Name:AUDY
Middle Name:EMILIO
Last Name:BLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 DEBARR RD SPC H20
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3179
Mailing Address - Country:US
Mailing Address - Phone:907-268-0825
Mailing Address - Fax:907-644-3072
Practice Address - Street 1:4110 DEBARR RD SPC H20
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3179
Practice Address - Country:US
Practice Address - Phone:907-268-0825
Practice Address - Fax:907-644-3072
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1111787171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator