Provider Demographics
NPI:1487646337
Name:FREESTONE, BLEN ARLOW (PA)
Entity Type:Individual
Prefix:
First Name:BLEN
Middle Name:ARLOW
Last Name:FREESTONE
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:PO BOX 1141
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535-1141
Mailing Address - Country:US
Mailing Address - Phone:435-587-3188
Mailing Address - Fax:435-587-3004
Practice Address - Street 1:364 W 100 N
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535-1054
Practice Address - Country:US
Practice Address - Phone:435-587-5054
Practice Address - Fax:435-587-3004
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106950-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P09903Medicare UPIN
UT005575103Medicare ID - Type UnspecifiedBLANDING CLINIC
UT006964003Medicare ID - Type UnspecifiedSAN JUAN CLINIC
UT006105011Medicare ID - Type UnspecifiedSJH ER