Provider Demographics
NPI:1063607398
Name:TREPA PA
Entity type:Organization
Organization Name:TREPA PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:BLASCHKE
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:615-979-9453
Mailing Address - Street 1:5400 MARYLAND WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5048
Mailing Address - Country:US
Mailing Address - Phone:615-979-9453
Mailing Address - Fax:
Practice Address - Street 1:605 HOLDERRIETH BLVD
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-6445
Practice Address - Country:US
Practice Address - Phone:281-401-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
TX363A00000X, 363L00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0057QCOtherBCBS
TX190652101Medicaid
TX0057QCOtherBCBS
TXDG5448Medicare PIN