Provider Demographics
NPI:1770932485
Name:BLONIEN, NICHOLAS EDWARD (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EDWARD
Last Name:BLONIEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL MEDICAL CTR
Mailing Address - Street 2:34800 BOB WILSON DRIVE
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:619-532-6827
Mailing Address - Fax:619-532-7508
Practice Address - Street 1:1665 UTICA AVE S STE 100
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-3476
Practice Address - Country:US
Practice Address - Phone:952-541-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
MN687762083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN