Healthcare Provider Details

I. General information

NPI: 1720619232
Provider Name (Legal Business Name): JACOB BLASINGAME PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER DR
MONTICELLO IL
61856-2116
US

IV. Provider business mailing address

1000 MEDICAL CENTER DR
MONTICELLO IL
61856-2116
US

V. Phone/Fax

Practice location:
  • Phone: 217-762-6241
  • Fax: 217-762-1702
Mailing address:
  • Phone: 217-762-2115
  • Fax: 217-762-1542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007530
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: