Healthcare Provider Details

I. General information

NPI: 1093791485
Provider Name (Legal Business Name): STANLEY AARON BLOUSTINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER
FT. LEWIS WA
98431
US

IV. Provider business mailing address

4912 88TH AVENUE CT W
UNIVERSITY PLACE WA
98467-1725
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2917
  • Fax:
Mailing address:
  • Phone: 253-565-4394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0017237
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: