Provider Demographics
NPI:1467097188
Name:BLANK, CAMERON (PA)
Entity Type:Individual
Prefix:MR
First Name:CAMERON
Middle Name:
Last Name:BLANK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13207 RAVENNA RD
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-1686
Mailing Address - Country:US
Mailing Address - Phone:216-844-7378
Mailing Address - Fax:
Practice Address - Street 1:13207 RAVENNA RD
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9523
Practice Address - Country:US
Practice Address - Phone:216-844-7378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-18
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1164435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty