Provider Demographics
NPI:1558739003
Name:BLALOCK, GARRETT (PA-C)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:BLALOCK
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 1:2081 CHULA BROOKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-2662
Mailing Address - Country:US
Mailing Address - Phone:229-402-4430
Mailing Address - Fax:
Practice Address - Street 1:901 18TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3648
Practice Address - Country:US
Practice Address - Phone:229-353-6051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7724363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical