Provider Demographics
NPI:1225057086
Name:BLEASE, DAVID CORLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CORLEY
Last Name:BLEASE
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 1:9313 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9155
Mailing Address - Country:US
Mailing Address - Phone:843-553-5616
Mailing Address - Fax:843-764-2917
Practice Address - Street 1:9313 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 304
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9155
Practice Address - Country:US
Practice Address - Phone:843-553-5616
Practice Address - Fax:843-764-2917
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA875363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0378PAMedicaid
SCQ57165Medicare UPIN
SCAA11671701Medicare PIN