Basic Information
| Provider Information | |||||||||
| NPI: | 1851726400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKKOLB | ||||||||
| FirstName: | REBECCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 FANNIN ST STE 1700 | ||||||||
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| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134869800 | ||||||||
| FaxNumber: | 2813923666 | ||||||||
| Practice Location | |||||||||
| Address1: | 23910 KATY FWY STE 201 | ||||||||
| Address2: | |||||||||
| City: | KATY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774941477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134869800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2013 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085-004703 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.