Provider Demographics
NPI:1720287170
Name:BLODGETT, STEPHANIE DAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DAWN
Last Name:BLODGETT
Suffix:
Gender:F
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 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2673
Mailing Address - Fax:
Practice Address - Street 1:23962 ALICIA PKWY STE I-1
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-3940
Practice Address - Country:US
Practice Address - Phone:949-452-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant