Basic Information
| Provider Information | |||||||||
| NPI: | 1396700449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAHA | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
| FaxNumber: | 6053129802 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 W 18TH ST STE G01 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571044651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053282663 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1962 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 9828 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0499 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1396700449 | 05 | MN | MEDICAID |