Provider Demographics
NPI:1871816595
Name:BLYDENBURGH, KRISTEN MARIE (RPA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:MARIE
Last Name:BLYDENBURGH
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 COVE RD S
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-1708
Mailing Address - Country:US
Mailing Address - Phone:631-680-7466
Mailing Address - Fax:
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:4TH FLOOR ANNEX
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:631-376-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant