Healthcare Provider Details

I. General information

NPI: 1164129318
Provider Name (Legal Business Name): JOSHUA MARK BLANCHARD RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR
TRAVIS AFB CA
94535-1802
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-3653
  • Fax:
Mailing address:
  • Phone: 707-423-3653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number6971173
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number7971173
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: