Provider Demographics
NPI:1609818665
Name:BLUM, SALLY S (PA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:S
Last Name:BLUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7060 WAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6527
Mailing Address - Country:US
Mailing Address - Phone:440-357-2770
Mailing Address - Fax:
Practice Address - Street 1:7060 WAYSIDE DR
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6527
Practice Address - Country:US
Practice Address - Phone:440-357-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051937363A00000X
MDC0005860363A00000X
OH50.004712RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant