Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 2006-00621 | NC |
N | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 2011003947 | MO |
NPI | 1619170529 |
---|---|
Provider Name | Deidra Blanks |
First Address | Fayetteville, NC 28304-3857 |
Second Address | Fayetteville, NC 28304-3857 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2007 |
Last Update Date | 11/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1619170529 | (05) | NC |