Provider Demographics
NPI:1427092089
Name:BLACKLEDGE, AARON VANCE (MD)
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:VANCE
Last Name:BLACKLEDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ROHNERT PARK HEALTHCARE CENTER
Practice Address - Street 2:1450 MEDICAL CENTER DRIVE
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928
Practice Address - Country:US
Practice Address - Phone:707-584-0672
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80152207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI109712Medicare UPIN
CA00A801522Medicare ID - Type Unspecified