Provider Demographics
NPI:1063869881
Name:GEISEL, BLAKEN
Entity type:Individual
Prefix:
First Name:BLAKEN
Middle Name:
Last Name:GEISEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-8300
Mailing Address - Country:US
Mailing Address - Phone:814-242-6171
Mailing Address - Fax:
Practice Address - Street 1:1115 ELKTON DR STE 300
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3597
Practice Address - Country:US
Practice Address - Phone:719-373-9703
Practice Address - Fax:877-588-3465
Is Sole Proprietor?:No
Enumeration Date:2016-05-22
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0008125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant