Provider Demographics
NPI:1104101823
Name:BLAZER, DOUGLAS ALAN (PA)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ALAN
Last Name:BLAZER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 S ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-2604
Mailing Address - Country:US
Mailing Address - Phone:815-874-8000
Mailing Address - Fax:
Practice Address - Street 1:3475 S ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2604
Practice Address - Country:US
Practice Address - Phone:815-874-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004130363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004130OtherSTATE MEDICAL LICENSE