Healthcare Provider Details

I. General information

NPI: 1013273143
Provider Name (Legal Business Name): BLAIR CAMILLE RUNDE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12493 UNIVERSITY AVE STE 100
CLIVE IA
50325-8286
US

IV. Provider business mailing address

PO BOX 1475
DES MOINES IA
50305-1475
US

V. Phone/Fax

Practice location:
  • Phone: 515-358-9461
  • Fax: 515-358-9489
Mailing address:
  • Phone: 515-358-9461
  • Fax: 515-358-9489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number101525
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5783
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: