Provider Demographics
NPI:1154708170
Name:BLAYLOCK, BENJAMIN (CRNA)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 MEADOW LARK DR
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50226
Mailing Address - Country:US
Mailing Address - Phone:515-494-9935
Mailing Address - Fax:
Practice Address - Street 1:1901 MEADOW LARK DR
Practice Address - Street 2:
Practice Address - City:POLK CITY
Practice Address - State:IA
Practice Address - Zip Code:50226-1283
Practice Address - Country:US
Practice Address - Phone:515-494-9935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD124963367500000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered