Provider Demographics
NPI:1225096670
Name:BLANTON-BIRZER, MONICA L (PA-C)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:L
Last Name:BLANTON-BIRZER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:325 MAINE STREET
Mailing Address - Street 2:MSO LIBRARY
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044
Mailing Address - Country:US
Mailing Address - Phone:785-505-2988
Mailing Address - Fax:785-505-5228
Practice Address - Street 1:1130 W 4TH ST STE 3204
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1345
Practice Address - Country:US
Practice Address - Phone:785-505-5815
Practice Address - Fax:785-505-5278
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500589363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
042065Medicare ID - Type Unspecified
P49866Medicare UPIN