Provider Demographics
NPI:1215418470
Name:BLOSE, MICHAEL CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHRISTOPHER
Last Name:BLOSE
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 1:211 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-2415
Mailing Address - Country:US
Mailing Address - Phone:814-952-1347
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:814-371-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059947363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical