Provider Demographics
NPI:1629079454
Name:THORNBLADE, S MICHELLE (PA C)
Entity Type:Individual
Prefix:
First Name:S
Middle Name:MICHELLE
Last Name:THORNBLADE
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:S
Other - Middle Name:MICHELLE
Other - Last Name:WESTPHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 N HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-3610
Mailing Address - Country:US
Mailing Address - Phone:410-576-1400
Mailing Address - Fax:410-576-7600
Practice Address - Street 1:3975 SAINT CHARLES PKWY
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2683
Practice Address - Country:US
Practice Address - Phone:301-645-6800
Practice Address - Fax:301-645-8696
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1421OtherLICENSE (EXPIRED)
TXPA02088OtherPA LICENSE (INACTIVE STAT
TXPA02088OtherPA LICENSE (INACTIVE STAT
8A3266Medicare ID - Type Unspecified