Provider Demographics
NPI:1720619232
Name:BLASINGAME, JACOB (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BLASINGAME
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-2116
Mailing Address - Country:US
Mailing Address - Phone:217-762-2115
Mailing Address - Fax:217-762-1542
Practice Address - Street 1:1000 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-2116
Practice Address - Country:US
Practice Address - Phone:217-762-6241
Practice Address - Fax:217-762-1702
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant