MEDICARE: KELSO LYNNE-BORRELL BLAZE

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	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255096707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSO LYNNE-BORRELL BLAZE

Provider Business Mailing Address
First Line	:	2530 N HOWARD ST UNIT 2
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133
Country	:	US
Telephone Number	:	732-744-4962
Fax Number	:

Provider Business Practice Location Address
First Line	:	2530 N HOWARD ST UNIT 2
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133
Country	:	US
Telephone Number	:	732-744-4962
Fax Number	:

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

Provider Enumeration Date	:	11/01/2021
Last Update Date	:	11/01/2021

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