Provider Demographics
NPI:1457008815
Name:MICHALAK, BLAIR NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:NICOLE
Last Name:MICHALAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BLAIR
Other - Middle Name:NICOLE
Other - Last Name:BOKELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4107 WILD AZALEA AVE APT 3722
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-0667
Mailing Address - Country:US
Mailing Address - Phone:720-308-3830
Mailing Address - Fax:
Practice Address - Street 1:309 NW RENFRO ST STE 201
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-3445
Practice Address - Country:US
Practice Address - Phone:817-295-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-06
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant