Provider Demographics
NPI:1790117356
Name:BLICK, BENJAMIN MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:BLICK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 BOW HUNTER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2458
Mailing Address - Country:US
Mailing Address - Phone:434-996-6303
Mailing Address - Fax:
Practice Address - Street 1:402 BOW HUNTER RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2458
Practice Address - Country:US
Practice Address - Phone:434-996-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV90749367500000X
WV77620367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered