Provider Demographics
NPI:1134825854
Name:BLAZO, MATTHEW FRANCIS (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:FRANCIS
Last Name:BLAZO
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 1:259 E ERIE ST STE 1900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3246
Mailing Address - Country:US
Mailing Address - Phone:312-695-7950
Mailing Address - Fax:312-695-5747
Practice Address - Street 1:259 E ERIE ST STE 1900
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3246
Practice Address - Country:US
Practice Address - Phone:312-695-7950
Practice Address - Fax:312-695-5747
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-03
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant