Provider Demographics
NPI:1417074907
Name:BLANCO, ROY L (APRN,MSN,FNP-C,PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:L
Last Name:BLANCO
Suffix:
Gender:M
Credentials:APRN,MSN,FNP-C,PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 VINTAGE CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2510
Mailing Address - Country:US
Mailing Address - Phone:209-623-8580
Mailing Address - Fax:
Practice Address - Street 1:7373 WEST LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3377
Practice Address - Country:US
Practice Address - Phone:209-476-2000
Practice Address - Fax:916-887-7920
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19007363A00000X
CANP 16596363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant