MEDICARE: TARA LYNN BLANK 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	363A00000X	Physician Assistant	5601003675	MI

General Provider Information

NPI Number	:	1841266053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA LYNN BLANK PA-C

Provider Business Mailing Address
First Line	:	3050 COMMERCE DR
Second Line	:	SUITE B
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3819
Country	:	US
Telephone Number	:	810-385-4441
Fax Number	:	810-385-1540

Provider Business Practice Location Address
First Line	:	1231 PINE GROVE AVE
Second Line	:	SUITE 2A
City	:	PORT HURON
State	:	MI
Zip	:	48060-3500
Country	:	US
Telephone Number	:	810-982-8742
Fax Number	:	810-984-8291

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

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	04/09/2010

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