Provider Demographics
NPI:1346768066
Name:BLAISDELL, ROBERT PAUL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:PAUL
Last Name:BLAISDELL
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 1:28 JOSEPH LN
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-2039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3815
Practice Address - Country:US
Practice Address - Phone:203-852-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant