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NPI Code Detail

MEDICARE: WANDA J. BLAYLARK MD

MEDICARE: WANDA J. BLAYLARK MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12083X0100XOccupational Medicine PhysicianA48420CA

General Provider Information

NPI Number : 1235198789
Entity Type Code : Individual
Provider Name (Legal Business Name) : WANDA J. BLAYLARK MD
Provider Business Mailing Address
First Line : 3400 DATA DR
Second Line : ATTN CREDENTIALING/PAYER ENROLLMENT
City : RANCHO CORDOVA
State : CA
Zip : 95670-7956
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 632 W GIBSON RD
Second Line :
City : WOODLAND
State : CA
Zip : 95695-5169
Country : US
Telephone Number : 530-668-2600
Fax Number : 530-669-5339
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/22/2006
Last Update Date : 08/07/2020

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Directions to “ WANDA J. BLAYLARK MD” Practice Location

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