Provider Demographics
NPI:1790717122
Name:BLAIN, BRIDGETTE C (PA - C)
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:C
Last Name:BLAIN
Suffix:
Gender:F
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:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66201-0716
Mailing Address - Country:US
Mailing Address - Phone:913-791-4357
Mailing Address - Fax:913-791-4435
Practice Address - Street 1:20333 W 151ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5350
Practice Address - Country:US
Practice Address - Phone:913-791-4357
Practice Address - Fax:913-791-4435
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200371000AMedicaid
KS43346012OtherBCBSKC
KSK54000009Medicare PIN