Provider Demographics
NPI:1992381743
Name:BLANCHARD, DERRICK (PA-C)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:BLANCHARD
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 1:3987 N LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-1482
Mailing Address - Country:US
Mailing Address - Phone:208-346-3010
Mailing Address - Fax:
Practice Address - Street 1:537 UNION AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5543
Practice Address - Country:US
Practice Address - Phone:541-507-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA204055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant