Provider Demographics
NPI:1790787745
Name:BLEASDALE, KIMBERLY DAWN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:BLEASDALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:PETRYSZYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8301 47TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4512
Mailing Address - Country:US
Mailing Address - Phone:763-504-4935
Mailing Address - Fax:763-504-4932
Practice Address - Street 1:8301 47TH AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-4512
Practice Address - Country:US
Practice Address - Phone:763-504-4935
Practice Address - Fax:763-504-4932
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10493363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000864Medicaid
WV3810000864Medicaid