Individual
JOHN MICHAEL BLANCO MATA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
3250 GATEWAY BLVD STE 112, PRESCOTT, AZ 86303-6856
(708) 248-0049
Mailing address
PO BOX 522, HUMBOLDT, AZ 86329-0522
(708) 248-0049
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
267971
AZ
363LA2100X
Acute Care Nurse Practitioner
267971
AZ
363LA2200X
Adult Health Nurse Practitioner
267971
AZ
363LC0200X
Critical Care Medicine Nurse Practitioner
267971
AZ
363LG0600X
Gerontology Nurse Practitioner
267971
AZ
Other
Enumeration date
03/20/2023
Last updated
01/31/2024
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