Provider Demographics
NPI:1306363700
Name:BLASIC, VANESSA ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ANNE
Last Name:BLASIC
Suffix:
Gender:F
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:PO BOX 33865
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3865
Mailing Address - Country:US
Mailing Address - Phone:858-888-7700
Mailing Address - Fax:
Practice Address - Street 1:320 SANTA FE DR STE 108
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5141
Practice Address - Country:US
Practice Address - Phone:760-436-4558
Practice Address - Fax:858-429-7926
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
CAPA54781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant