Provider Demographics
NPI:1295311553
Name:BLUST, SAMANTHA ROSE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:BLUST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 BISCHOFF RD
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9224
Mailing Address - Country:US
Mailing Address - Phone:989-305-2666
Mailing Address - Fax:
Practice Address - Street 1:4040 BEACON ST
Practice Address - Street 2:
Practice Address - City:KINGSLEY
Practice Address - State:MI
Practice Address - Zip Code:49649-9548
Practice Address - Country:US
Practice Address - Phone:231-263-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program