Provider Demographics
NPI:1093955593
Name:BLAZE, JODEE L (CRNA)
Entity Type:Individual
Prefix:
First Name:JODEE
Middle Name:L
Last Name:BLAZE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4421
Mailing Address - Country:US
Mailing Address - Phone:701-234-6258
Mailing Address - Fax:
Practice Address - Street 1:737 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4421
Practice Address - Country:US
Practice Address - Phone:701-234-6258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 152598-2367500000X
NDR34791367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1093955593Medicaid
MNP00733656OtherMEDICARE RAILROAD
MNP00733656OtherMEDICARE RAILROAD
MN1093955593Medicaid