Provider Demographics
NPI:1689718579
Name:BLESOFSKY, MARSHALL EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:EDWARD
Last Name:BLESOFSKY
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 1:3917 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2714
Mailing Address - Country:US
Mailing Address - Phone:562-760-8823
Mailing Address - Fax:562-252-8242
Practice Address - Street 1:3917 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2714
Practice Address - Country:US
Practice Address - Phone:562-760-8823
Practice Address - Fax:562-252-8242
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 11155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 11155OtherPHYSICIAN ASSISTANT LICEN
CAPA 11155OtherPHYSICIAN ASSISTANT LICEN
CAEN188YMedicare PIN