Provider Demographics
NPI:1710623848
Name:BLANCO, PEDRO ANTONIO JR (BA)
Entity Type:Individual
Prefix:MR
First Name:PEDRO
Middle Name:ANTONIO
Last Name:BLANCO
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W 144TH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031
Mailing Address - Country:US
Mailing Address - Phone:347-882-7563
Mailing Address - Fax:
Practice Address - Street 1:520 W 144TH ST APT 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-5833
Practice Address - Country:US
Practice Address - Phone:646-652-9025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator