Provider Demographics
NPI:1124589262
Name:BLASKOWSKI, NATALIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:MARIE
Last Name:BLASKOWSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:MARIE
Other - Last Name:PLASCENCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:900 ROUND VALLEY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7552
Mailing Address - Country:US
Mailing Address - Phone:435-656-6600
Mailing Address - Fax:
Practice Address - Street 1:900 ROUND VALLEY DR STE 100
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7552
Practice Address - Country:US
Practice Address - Phone:435-656-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
UT11504426-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant