Provider Demographics
NPI:1841629052
Name:BLEA, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:BLEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:SPRINGER
Mailing Address - State:NM
Mailing Address - Zip Code:87747-0488
Mailing Address - Country:US
Mailing Address - Phone:575-483-2682
Mailing Address - Fax:575-483-2670
Practice Address - Street 1:606 COLBERT AVENUE
Practice Address - Street 2:
Practice Address - City:SPRINGER
Practice Address - State:NM
Practice Address - Zip Code:87747-0488
Practice Address - Country:US
Practice Address - Phone:575-483-2682
Practice Address - Fax:575-483-2670
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM00022536146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM856000746Medicare PIN