MEDICARE: CHEYENNE LEA BLANTON 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	PA3823	KY
2	363AS0400X	Surgical Physician Assistant	PA3823	KY
3	363A00000X	Physician Assistant	PA2017-0093	NM
4	363A00000X	Physician Assistant	PA3823	KY

General Provider Information

NPI Number	:	1891214755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHEYENNE LEA BLANTON PA-C

Provider Business Mailing Address
First Line	:	4824 MCMAHON BLVD NW STE 109
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-5412
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4824 MCMAHON BLVD NW STE 109
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-5412
Country	:	US
Telephone Number	:	505-558-7246
Fax Number	:

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

Provider Enumeration Date	:	09/12/2017
Last Update Date	:	05/11/2026

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