Provider Demographics
NPI:1922420553
Name:BLANCO, JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
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 1:75TH MDG
Mailing Address - Street 2:7321 BALMER AVE BLDG 570
Mailing Address - City:HILL AFB
Mailing Address - State:UT
Mailing Address - Zip Code:84056-5012
Mailing Address - Country:US
Mailing Address - Phone:801-777-5721
Mailing Address - Fax:
Practice Address - Street 1:RAF LAKENHEATH 48 MDG/SGHC
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09461-5115
Practice Address - Country:US
Practice Address - Phone:01144163-852-8124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
UT11710873-1206363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant