Provider Demographics
NPI:1265735369
Name:BLAQUIERE, KEITH P (PA)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:P
Last Name:BLAQUIERE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 GRAND OAK RD
Mailing Address - Street 2:
Mailing Address - City:FORESTDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02644-1202
Mailing Address - Country:US
Mailing Address - Phone:508-566-2429
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:508-566-2429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-10
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant