MEDICARE: MELAINA ZANELE BLOMENKAMP PA-C

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	363AM0700X	Medical Physician Assistant	2731	AZ

General Provider Information

NPI Number	:	1780605048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELAINA ZANELE BLOMENKAMP PA-C

Provider Business Mailing Address
First Line	:	410 BRITE DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-7088
Country	:	US
Telephone Number	:	928-854-2542
Fax Number	:

Provider Business Practice Location Address
First Line	:	3269 STOCKTON HILL RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-3619
Country	:	US
Telephone Number	:	928-757-2101
Fax Number	:

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

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	06/30/2009

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