Provider Demographics
NPI:1396503843
Name:BLANSHAN, MATT (CPRS)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:BLANSHAN
Suffix:
Gender:M
Credentials:CPRS
Other - Prefix:
Other - First Name:MATHEW
Other - Middle Name:
Other - Last Name:BLANSHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPRS
Mailing Address - Street 1:1826 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1800
Mailing Address - Country:US
Mailing Address - Phone:507-229-0350
Mailing Address - Fax:507-216-0371
Practice Address - Street 1:1826 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-1800
Practice Address - Country:US
Practice Address - Phone:507-229-0350
Practice Address - Fax:507-216-0371
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9613175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
9613OtherCPRS CERTIFICATION