Provider Demographics
NPI:1609916410
Name:BLANCHETTE, MARY (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BLANCHETTE
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 1:291 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3628
Mailing Address - Country:US
Mailing Address - Phone:617-541-6540
Mailing Address - Fax:617-541-7503
Practice Address - Street 1:69 REEDSDALE RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-3309
Practice Address - Country:US
Practice Address - Phone:617-512-6893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS16819Medicare UPIN