MEDICARE: SPENCER JUSTIN BLAKELY CAA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367H00000X	Anesthesiologist Assistant

General Provider Information

NPI Number	:	1134082803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPENCER JUSTIN BLAKELY CAA

Provider Business Mailing Address
First Line	:	2401 W UNIVERSITY AVE
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47303-3428
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 W UNIVERSITY AVE
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47303-3428
Country	:	US
Telephone Number	:	765-747-3111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2025
Last Update Date	:	12/08/2025

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