Healthcare Provider Details

I. General information

NPI: 1710758065
Provider Name (Legal Business Name): BAILEE MARIA BLICKENSDERFER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 06/16/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 CAREGIVER CIR
RAPID CITY SD
57702-8529
US

IV. Provider business mailing address

215 W OWENS AVE
BISMARCK ND
58501-1608
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
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: