Provider Demographics
NPI:1952930109
Name:BLAINE, CHRIS
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:BLAINE
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 1:4300 E FLAMINGO AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-3138
Mailing Address - Country:US
Mailing Address - Phone:208-205-3013
Mailing Address - Fax:
Practice Address - Street 1:12652 S AREZZO WAY
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8276
Practice Address - Country:US
Practice Address - Phone:208-709-5513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1870207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine