Provider Demographics
NPI:1831284918
Name:BLAND, LEE G (PA-C)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:G
Last Name:BLAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARION
Other - Middle Name:LEE
Other - Last Name:BAIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:22 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:HOULTON
Mailing Address - State:ME
Mailing Address - Zip Code:04730-1891
Mailing Address - Country:US
Mailing Address - Phone:859-224-9581
Mailing Address - Fax:859-224-9497
Practice Address - Street 1:22 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-1891
Practice Address - Country:US
Practice Address - Phone:859-224-9581
Practice Address - Fax:859-224-9497
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA022363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCB5773OtherRR MEDICARE LAB GROUP
KY37903705OtherMEDICAID LAB GROUP
KY4000501OtherMEDICARE LAB GROUP
KY95000220Medicaid
R98989Medicare UPIN
KY95000220Medicaid