Provider Demographics
NPI:1891838801
Name:UPHAM, BLAINE G (DC)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:G
Last Name:UPHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5461 E MAYFLOWER LN STE 6
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7892
Mailing Address - Country:US
Mailing Address - Phone:907-357-6688
Mailing Address - Fax:907-357-9655
Practice Address - Street 1:5461 E MAYFLOWER LN STE 6
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7892
Practice Address - Country:US
Practice Address - Phone:907-357-6688
Practice Address - Fax:907-357-9655
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5347111N00000X
AK584111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ74557Medicare ID - Type Unspecified
AZ680545951Medicare UPIN