Provider Demographics
NPI:1669468385
Name:WALTERSDORF, BLYTHE D (PA)
Entity Type:Individual
Prefix:
First Name:BLYTHE
Middle Name:D
Last Name:WALTERSDORF
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1610 W TOWNLINE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-1066
Mailing Address - Country:US
Mailing Address - Phone:641-782-2131
Mailing Address - Fax:641-782-6425
Practice Address - Street 1:1610 W TOWNLINE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-1066
Practice Address - Country:US
Practice Address - Phone:641-782-2131
Practice Address - Fax:641-782-6425
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA001293363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
I1331Medicare ID - Type Unspecified
IAP24593Medicare UPIN