Provider Demographics
NPI:1407684905
Name:BLAZESKI, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BLAZESKI
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 1:60 SINSABAUGH RD
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-5461
Mailing Address - Country:US
Mailing Address - Phone:845-978-5121
Mailing Address - Fax:
Practice Address - Street 1:11 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2027
Practice Address - Country:US
Practice Address - Phone:845-672-3995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032493363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant