Provider Demographics
NPI:1558340844
Name:BLAINE, CLINTON JED (PA)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:JED
Last Name:BLAINE
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 1:3500 PURDY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-8050
Mailing Address - Country:US
Mailing Address - Phone:541-731-4672
Mailing Address - Fax:
Practice Address - Street 1:3500 PURDY RD
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-8050
Practice Address - Country:US
Practice Address - Phone:731-986-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA161186363A00000X
TNPA892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1509074Medicaid
TN3380640OtherGROUP MEDICARE
TN3380640OtherGROUP MEDICAID
TNPA892OtherPROFESSIONAL LICENSE
OR1558340844Medicaid
TN3380640OtherGROUP MEDICARE
TN1509074Medicaid