Healthcare Provider Details

I. General information

NPI: 1912832346
Provider Name (Legal Business Name): CYRUSS JOHN WANE BLEWETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3568 GERAGHTY AVE
FAIRBANKS AK
99709-4701
US

IV. Provider business mailing address

3568 GERAGHTY AVE
FAIRBANKS AK
99709-4701
US

V. Phone/Fax

Practice location:
  • Phone: 907-405-2645
  • Fax:
Mailing address:
  • Phone: 907-206-7402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: