Provider Demographics
NPI:1790790483
Name:BLANKENSHIP, ELIZABETH BOLES (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BOLES
Last Name:BLANKENSHIP
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:BOLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-8759
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-8759
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1000477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
190684OtherMEDCOST
7254848OtherAETNA
P00397963OtherRR MEDICARE
P00397963OtherRR MEDICARE