Provider Demographics
NPI:1306039490
Name:BLAKESLEE, WILLIAM HARTLEY III (WILLIAM BLAKESLEE PA)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:HARTLEY
Last Name:BLAKESLEE
Suffix:III
Gender:M
Credentials:WILLIAM BLAKESLEE PA
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Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 74
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8481
Mailing Address - Fax:269-341-7781
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 74
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8481
Practice Address - Fax:269-341-7781
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2014-10-31
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Provider Licenses
StateLicense IDTaxonomies
MI5601005112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417961137OtherBCBSM - BRONSON
MI1306039490Medicaid
MI1306039490Medicaid