Healthcare Provider Details

I. General information

NPI: 1326125485
Provider Name (Legal Business Name): JACOB I. BLAZZARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 5TH ST
CLARKSTON WA
99403-2714
US

IV. Provider business mailing address

4700 EXCHANGE CT STE 110
BOCA RATON FL
33431-4450
US

V. Phone/Fax

Practice location:
  • Phone: 509-758-5141
  • Fax: 509-758-5299
Mailing address:
  • Phone: 561-948-0291
  • Fax: 561-859-0429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60099484
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1221
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.PA.60099484
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number361
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: