Provider Demographics
NPI:1356961015
Name:BLANK, ALEXANDER (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:BLANK
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 1:111 W WASHINGTON ST STE 1801
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3430
Mailing Address - Country:US
Mailing Address - Phone:312-695-8106
Mailing Address - Fax:312-694-1340
Practice Address - Street 1:111 W WASHINGTON ST STE 1801
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3430
Practice Address - Country:US
Practice Address - Phone:312-695-8106
Practice Address - Fax:312-694-1340
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085007989363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program