Provider Demographics
NPI:1093789414
Name:BLAU, MICHAEL S (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:BLAU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-277-2225
Mailing Address - Fax:336-277-2231
Practice Address - Street 1:190 KIMEL PARK DR STE 140
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-277-2225
Practice Address - Fax:336-277-2231
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC103449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102570Medicaid
NCS22144Medicare UPIN
NCNC8381BMedicare PIN