Provider Demographics
NPI:1760787386
Name:PAWELKA, BLAIR MARIE (IDC)
Entity Type:Individual
Prefix:MS
First Name:BLAIR
Middle Name:MARIE
Last Name:PAWELKA
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS FREEDOM
Mailing Address - Street 2:LCS-1
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96665-0102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USS FREEDOM
Practice Address - Street 2:LCS-1
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96665-0102
Practice Address - Country:US
Practice Address - Phone:619-556-5343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman