Provider Demographics
NPI:1629060801
Name:BLUM, STEVEN WILLIAM (PA C FNP C)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:WILLIAM
Last Name:BLUM
Suffix:
Gender:M
Credentials:PA C FNP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:CHARLES CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50616-3444
Mailing Address - Country:US
Mailing Address - Phone:641-228-5151
Mailing Address - Fax:641-228-2902
Practice Address - Street 1:1501 S MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:CHARLES CITY
Practice Address - State:IA
Practice Address - Zip Code:50616-3444
Practice Address - Country:US
Practice Address - Phone:641-228-5151
Practice Address - Fax:641-228-2902
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000828363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970008132OtherRR MEDICARE
R02972Medicare UPIN
06578Medicare ID - Type Unspecified