1093851693 NPI number — CRAIG A BLANKINSHIP MSPT

Table of content: CRAIG A BLANKINSHIP MSPT (NPI 1093851693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093851693 NPI number — CRAIG A BLANKINSHIP MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANKINSHIP
Provider First Name:
CRAIG
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093851693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
734 E ELGIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85296-6580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-855-5542
Provider Business Mailing Address Fax Number:
480-855-5756

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1534 E RAY RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85296-4429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-855-5542
Provider Business Practice Location Address Fax Number:
480-855-5756
Provider Enumeration Date:
01/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4181 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)