Healthcare Provider Details

I. General information

NPI: 1245803584
Provider Name (Legal Business Name): MATTHEW BLEGEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 23RD ST NW
WASHINGTON DC
20037-2342
US

IV. Provider business mailing address

1000 6TH ST SW APT 311
WASHINGTON DC
20024-2669
US

V. Phone/Fax

Practice location:
  • Phone: 202-715-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200001192
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: