Provider Demographics
NPI:1174634562
Name:BLANKENSHIP, KRISTIN (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19653
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9653
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-2588
Practice Address - Street 1:747 N RUTLEDGE ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6700
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-2588
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004979363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00653958OtherRAILROAD MEDICARE
431560263OtherTRICARE WEST
MO132680008Medicare PIN
ILF400175181Medicare PIN