Provider Demographics
NPI:1912284530
Name:BLIZZARD, IAN A (PA-C)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:A
Last Name:BLIZZARD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:405 SILVERSIDE RD STE 111
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-1768
Mailing Address - Country:US
Mailing Address - Phone:302-798-0666
Mailing Address - Fax:302-798-4905
Practice Address - Street 1:2600 GLASGOW AVE STE 124
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-4777
Practice Address - Country:US
Practice Address - Phone:302-836-4200
Practice Address - Fax:302-836-8431
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS567Medicare PIN