Provider Demographics
NPI:1609802123
Name:BLAHA, LINDSEY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LINDSEY
Middle Name:
Last Name:BLAHA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LINDSEY
Other - Middle Name:
Other - Last Name:KOENIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 63B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-983-4700
Practice Address - Fax:314-692-9862
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004032520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO691844OtherHEALTHLINK
MO195930OtherBLUE CROSS BLUE SHIELD
MO691844OtherHEALTHLINK
Q36553Medicare UPIN