Provider Demographics
NPI:1497295505
Name:YERBY, BLAYNE O (PA)
Entity Type:Individual
Prefix:
First Name:BLAYNE
Middle Name:O
Last Name:YERBY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BLAYNE
Other - Middle Name:O
Other - Last Name:FRISBIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:789 W DUVAL ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-3811
Mailing Address - Country:US
Mailing Address - Phone:386-755-5044
Mailing Address - Fax:386-755-2283
Practice Address - Street 1:1419 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-4624
Practice Address - Country:US
Practice Address - Phone:904-653-1822
Practice Address - Fax:904-259-1225
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9110127363A00000X
FLPA9110127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020253400Medicaid