GREGORY W BLANK Physician Assistant License verification

Business Entity

INACTIVE

License Type

Physician Assistant

Description

LICENSED PHYSICIAN ASSISTANT

License Number

085002018

License Status

INACTIVE

Business

First Name

GREGORY

Middle

Last Name

BLANK

Business Name

GREGORY W BLANK

Original Issue Date

07/02/2003

Effective Date

07/02/2003

Expiration Date

03/01/2006

City

SPRINGFIELD

State

Zip

62707

County

SANGAMON

Ever Disciplined

LastModifiedDate

10/09/2006