Provider Demographics
NPI:1558971432
Name:BLANKENBURG, KRISTIANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIANNE
Middle Name:
Last Name:BLANKENBURG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIANNE
Other - Middle Name:
Other - Last Name:GORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:655 E REDD RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-1242
Mailing Address - Country:US
Mailing Address - Phone:915-303-5522
Mailing Address - Fax:
Practice Address - Street 1:655 E REDD RD BLDG B
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-1242
Practice Address - Country:US
Practice Address - Phone:915-303-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15142363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant