Basic Information
Provider Information | |||||||||
NPI: | 1184786592 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLASKO | ||||||||
FirstName: | DANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7800 SW 87TH AVE | ||||||||
Address2: | SUITE C-340 | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331733570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055950109 | ||||||||
FaxNumber: | 3055957092 | ||||||||
Practice Location | |||||||||
Address1: | 7800 SW 87TH AVE | ||||||||
Address2: | SUITE C-340 | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331733570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055950109 | ||||||||
FaxNumber: | 3055957092 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA003475 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | PA003475 | 01 | FL | PA LICENSE | OTHER |