Provider Demographics
NPI:1144238627
Name:BLADES-CLARKE, DEBORAH RENEE (NP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:RENEE
Last Name:BLADES-CLARKE
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 1:1 PENN PLZ
Mailing Address - Street 2:7TH FLOOR, SUITE 725
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10119-0002
Mailing Address - Country:US
Mailing Address - Phone:917-626-8996
Mailing Address - Fax:
Practice Address - Street 1:1 PENN PLZ
Practice Address - Street 2:7TH FLOOR, SUITE 725
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10119-0002
Practice Address - Country:US
Practice Address - Phone:917-626-8996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3018541363LA2200X
NY301854363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01915388Medicaid