Provider Demographics
NPI:1629174412
Name:MCDANIEL, BLAISE POPE (PA)
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:POPE
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8764 BLAIN HWY
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-8644
Mailing Address - Country:US
Mailing Address - Phone:740-773-7669
Mailing Address - Fax:740-596-0871
Practice Address - Street 1:17273 STATE ROUTE 104
Practice Address - Street 2:116A1
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8608
Practice Address - Country:US
Practice Address - Phone:740-773-1141
Practice Address - Fax:740-772-7096
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH1004772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant