Provider Demographics
NPI:1912634866
Name:BLAIS, CHRISTIAN (PA)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:BLAIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W 87TH ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3562
Mailing Address - Country:US
Mailing Address - Phone:203-731-4669
Mailing Address - Fax:
Practice Address - Street 1:600 E 233RD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2604
Practice Address - Country:US
Practice Address - Phone:718-920-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX0012658062Medicaid