Provider Demographics
NPI:1174829774
Name:BLANKENHEIM, LUKE JOHNATHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:JOHNATHAN
Last Name:BLANKENHEIM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8926 WOODYARD RD
Mailing Address - Street 2:SUITE 701
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-4220
Mailing Address - Country:US
Mailing Address - Phone:301-856-1682
Mailing Address - Fax:301-856-8214
Practice Address - Street 1:8926 WOODYARD RD
Practice Address - Street 2:SUITE 701
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-4220
Practice Address - Country:US
Practice Address - Phone:301-856-1682
Practice Address - Fax:301-856-8214
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004416363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI2264OtherRAILROAD MEDICARE GROUP PTAN
C0004416OtherMARYLAND LICENSE
P00992732OtherRAILROAD MEDICARE INDIVIDUAL PTAN
P00992732OtherRAILROAD MEDICARE INDIVIDUAL PTAN
CI2264OtherRAILROAD MEDICARE GROUP PTAN