Provider Demographics
NPI:1124100300
Name:BLASKO, MICHAEL P (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL P
Middle Name:
Last Name:BLASKO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4631 TELLER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8105
Mailing Address - Country:US
Mailing Address - Phone:949-335-7500
Mailing Address - Fax:949-387-1206
Practice Address - Street 1:4631 TELLER AVE STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8105
Practice Address - Country:US
Practice Address - Phone:949-335-7500
Practice Address - Fax:949-387-1206
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA00000PA17281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant