Provider Demographics
NPI:1750474177
Name:BLAKESPEAR, JEREMY DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DANIEL
Last Name:BLAKESPEAR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:DANIEL
Other - Last Name:SPEARMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:150 VALPREDA RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2973
Mailing Address - Country:US
Mailing Address - Phone:760-736-6767
Mailing Address - Fax:
Practice Address - Street 1:3220 MISSION AVE STE 1
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1354
Practice Address - Country:US
Practice Address - Phone:760-433-3155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51942131206363A00000X, 363AM0700X
CAPA 19825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP74502Medicare UPIN