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General NPI Number Information
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NPI Number | 1639871247
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Entity Type | Individual
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Provider Name | JOHN MICHAEL BLANCO MATA NP
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Gender | Male
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Dates
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Enumeration Date | 03/20/2023
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Last Update Date | 01/31/2024
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Provider Practice Location Address
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Address Line | 3250 GATEWAY BLVD STE 112
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City | PRESCOTT
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State | AZ
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Zip | 86303-6856
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Country | US
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Telephone | 708-248-0049
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 522
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City | HUMBOLDT
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State | AZ
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Zip | 86329-0522
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Country | US
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Telephone | 708-248-0049
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 267971
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 267971
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 363LC0200X
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Taxonomy Name | Critical Care Medicine Nurse Practitioner
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License Number | 267971
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License Number State | AZ
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Taxonomy #4
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 267971
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License Number State | AZ
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Taxonomy #5
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 267971
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License Number State | AZ
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