Provider Demographics
NPI:1093788994
Name:BLASCHKA, RAE JEAN (NP)
Entity Type:Individual
Prefix:
First Name:RAE JEAN
Middle Name:
Last Name:BLASCHKA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6505
Mailing Address - Country:US
Mailing Address - Phone:907-486-6065
Mailing Address - Fax:907-486-2248
Practice Address - Street 1:1818 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6505
Practice Address - Country:US
Practice Address - Phone:907-486-6065
Practice Address - Fax:907-486-2248
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNP7235363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDNP7235Medicaid
OSOWCHHTAMedicare ID - Type Unspecified
MDNP7235Medicaid
R61920Medicare UPIN