Provider Demographics
NPI:1811162852
Name:BLADES, MAGEN MORINE (PA)
Entity type:Individual
Prefix:MRS
First Name:MAGEN
Middle Name:MORINE
Last Name:BLADES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MAGEN
Other - Middle Name:MORINE
Other - Last Name:BRUNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1242 E. INDEPENDENCE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-883-5500
Mailing Address - Fax:417-883-5577
Practice Address - Street 1:1242 E. INDEPENDENCE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-883-5500
Practice Address - Fax:417-883-5577
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008009941363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1811162852OtherTRICARE
MOP00957131OtherPALMETTO GBA RAILROAD
MO502280057Medicare Oscar/Certification
MO155310001Medicare PIN