Provider Demographics
NPI:1477991446
Name:BLATY, TANYA SUE (DO)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:SUE
Last Name:BLATY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:TANYA
Other - Middle Name:SUE
Other - Last Name:LISKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-232-2390
Practice Address - Street 1:750 N SYRINGA ST STE 206B
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-262-2439
Practice Address - Fax:208-508-2259
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1230207R00000X, 207RE0101X, 207RE0101X
MN63717207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1477991446Medicaid
WA2136132Medicaid