Basic Information
| Provider Information | |||||||||
| NPI: | 1366932287 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLON | ||||||||
| FirstName: | MAMATA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12070 OLD LINE CTR | ||||||||
| Address2: | STE 303 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206023535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016455100 | ||||||||
| FaxNumber: | 4439490825 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 GARRETT AVE | ||||||||
| Address2: | |||||||||
| City: | LA PLATA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206465960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016094000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2018 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C06809 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.