Basic Information
| Provider Information | |||||||||
| NPI: | 1932425139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLASZAK | ||||||||
| FirstName: | FAYE | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743294 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976303 | ||||||||
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| Practice Location | |||||||||
| Address1: | BON SECOURS NEUROLOGY | ||||||||
| Address2: | 801 ROPER CREEK DRIVE | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645161170 | ||||||||
| FaxNumber: | 8772499483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 4179 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | NP1604 | 05 | SC | MEDICAID | APPROVED | 05 | SC | MEDICAID |