Basic Information
| Provider Information | |||||||||
| NPI: | 1174829774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANKENHEIM | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | JOHNATHAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8926 WOODYARD RD | ||||||||
| Address2: | SUITE 701 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207354220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018561682 | ||||||||
| FaxNumber: | 3018568214 | ||||||||
| Practice Location | |||||||||
| Address1: | 8926 WOODYARD RD | ||||||||
| Address2: | SUITE 701 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207354220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018561682 | ||||||||
| FaxNumber: | 3018568214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C0004416 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | CI2264 | 01 | RAILROAD MEDICARE GROUP PTAN | OTHER | C0004416 | 01 | MARYLAND LICENSE | OTHER | P00992732 | 01 | RAILROAD MEDICARE INDIVIDUAL PTAN | OTHER |