Healthcare Provider Details

I. General information

NPI: 1255809109
Provider Name (Legal Business Name): JUSTIN BLASDEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 LONE PINE RD
MEDFORD OR
97504
US

IV. Provider business mailing address

300 W MAIN ST
MEDFORD OR
97501-2756
US

V. Phone/Fax

Practice location:
  • Phone: 541-772-1777
  • Fax:
Mailing address:
  • Phone: 541-772-1777
  • Fax: 541-734-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2470A2800X
TaxonomyAssistant Health Information Record Technician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: