Healthcare Provider Details

I. General information

NPI: 1760142699
Provider Name (Legal Business Name): ADAM ROBERT BLANTON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13938 MIDDLE GIBRALTAR RD
GIBRALTAR MI
48173-9711
US

IV. Provider business mailing address

13938 MIDDLE GIBRALTAR RD
GIBRALTAR MI
48173-9711
US

V. Phone/Fax

Practice location:
  • Phone: 313-484-3211
  • Fax: 313-710-4520
Mailing address:
  • Phone: 313-484-3211
  • Fax: 313-710-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number470432094
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: