Provider Demographics
NPI:1649590365
Name:BLAISDELL, LAUREN (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BLAISDELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11835 RT 9W
Mailing Address - Street 2:
Mailing Address - City:WEST COXSACKIE
Mailing Address - State:NY
Mailing Address - Zip Code:12192-3605
Mailing Address - Country:US
Mailing Address - Phone:518-731-9000
Mailing Address - Fax:
Practice Address - Street 1:11835 RT 9W
Practice Address - Street 2:
Practice Address - City:WEST COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12192-3605
Practice Address - Country:US
Practice Address - Phone:518-731-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant