Provider Demographics
NPI:1477710622
Name:LAM, CASSIE BLANKENSHIP
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:BLANKENSHIP
Last Name:LAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASSIE
Other - Middle Name:MARIA
Other - Last Name:BLANKENSHIP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-766-9737
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:500 J CLYDE MORRIS BLVD
Practice Address - Street 2:RIVERSIDE REGIONAL MEDICAL CENTER
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-594-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101250862207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPENDINGMedicaid
VAPENDINGMedicaid