Provider Demographics
NPI:1619173010
Name:BLODGETT, KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BLODGETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 SULLIVAN AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2221
Mailing Address - Country:US
Mailing Address - Phone:650-756-5630
Mailing Address - Fax:650-756-0136
Practice Address - Street 1:1850 SULLIVAN AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2221
Practice Address - Country:US
Practice Address - Phone:650-756-5630
Practice Address - Fax:650-756-0136
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00615831OtherMEDICARE RR
CAPA19212OtherSTATE LICENSE
CA0PA192120Medicare PIN