Provider Demographics
NPI:1508258856
Name:BLANTON, ADAM C (PA)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:C
Last Name:BLANTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25708-0390
Mailing Address - Country:US
Mailing Address - Phone:304-429-1088
Mailing Address - Fax:304-429-3109
Practice Address - Street 1:61 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3530
Practice Address - Country:US
Practice Address - Phone:043-443-0233
Practice Address - Fax:043-236-3110
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC366363A00000X
KYPA1983363A00000X
OH50.004709RX363A00000X
SC2775363A00000X
WV700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0174794Medicaid
WV1508258856Medicaid