Healthcare Provider Details

I. General information

NPI: 1073277083
Provider Name (Legal Business Name): BLAISE IGNACIOUS RONNAU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 E WICHITA AVE
RUSSELL KS
67665-2444
US

IV. Provider business mailing address

2776 OUTRIDER CT
CHEYENNE WY
82009-7512
US

V. Phone/Fax

Practice location:
  • Phone: 785-657-7464
  • Fax:
Mailing address:
  • Phone: 307-365-4475
  • 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: