Basic Information
| Provider Information | |||||||||
| NPI: | 1780657791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANCHARD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLANCHARD | ||||||||
| OtherFirstName: | DAVID | ||||||||
| OtherMiddleName: | EVERARD | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 505 336TH STREET | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 COLLEGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829015868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073528350 | ||||||||
| FaxNumber: | 3073528178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 7418A | WY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | TL659 | WY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | AB0094633 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | AB2307569 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | J3743 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 1780657791 | 05 | WY | MEDICAID | 314473 | 01 | WY | BCWY | OTHER | 123163400 | 05 | WY | MEDICAID | 605960009 | 01 | WY | USDLAB | OTHER |