MEDICARE: BLANCO FAMILY MEDICINE, PLLC

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	207Q00000X	Family Medicine Physician	025209 MD00036490	WA

General Provider Information

NPI Number	:	1588846091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLANCO FAMILY MEDICINE, PLLC

Provider Business Mailing Address
First Line	:	436 MCPHEE RD SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-5014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	436 MCPHEE RD SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-5014
Country	:	US
Telephone Number	:	360-352-7779
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	VIVIAN BLANCO
Credential	:	MD
Telephone Number	:	360-352-7779

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	11/27/2007

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