Provider Demographics
NPI:1639508526
Name:BLADES, MEAGAN KATHERINE (PA)
Entity Type:Individual
Prefix:MRS
First Name:MEAGAN
Middle Name:KATHERINE
Last Name:BLADES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MEAGAN
Other - Middle Name:KATHERINE
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:399E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4815
Mailing Address - Country:US
Mailing Address - Phone:909-503-1283
Mailing Address - Fax:909-503-1286
Practice Address - Street 1:18300 OUTER HWY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-242-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant