Basic Information
| Provider Information | |||||||||
| NPI: | 1477710622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAM | ||||||||
| FirstName: | CASSIE | ||||||||
| MiddleName: | BLANKENSHIP | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLANKENSHIP | ||||||||
| OtherFirstName: | CASSIE | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037669737 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 J CLYDE MORRIS BLVD | ||||||||
| Address2: | RIVERSIDE REGIONAL MEDICAL CENTER | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575942000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
| 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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207LP2900X | 0101250862 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | VA | MEDICAID |