Provider Demographics
NPI:1598738635
Name:BLAIR, TRINA GEBAUER (PAC)
Entity Type:Individual
Prefix:MRS
First Name:TRINA
Middle Name:GEBAUER
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TRINA
Other - Middle Name:
Other - Last Name:GEBAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3415 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-6976
Mailing Address - Country:US
Mailing Address - Phone:563-742-4350
Mailing Address - Fax:563-742-4355
Practice Address - Street 1:3415 53RD AVE
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-6976
Practice Address - Country:US
Practice Address - Phone:563-742-4350
Practice Address - Fax:563-742-4355
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002304363A00000X
IA001563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1598738635Medicaid
P00277546OtherMEDICARE RAILROAD
116106OtherHEALTH ALLIANCE
IA37592OtherBLUE CROSS BLUE SHIELD
Q25968Medicare UPIN
IA1598738635Medicaid
ILK11946Medicare PIN
IAI13271Medicare PIN