Provider Demographics
NPI:1316313562
Name:BINDOULA, BLAISE AUGUSTE
Entity type:Individual
Prefix:MR
First Name:BLAISE
Middle Name:AUGUSTE
Last Name:BINDOULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49725 COUNTY 83
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479-5280
Mailing Address - Country:US
Mailing Address - Phone:218-894-8423
Mailing Address - Fax:218-894-8943
Practice Address - Street 1:49725 COUNTY 83
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479-5280
Practice Address - Country:US
Practice Address - Phone:218-894-1515
Practice Address - Fax:218-894-8767
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR191271-5163WH0200X
MNCNP5148363LG0600X, 363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care