Provider Demographics
NPI:1881686590
Name:ETZEL, BLAINE C (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:C
Last Name:ETZEL
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 1:120 WILLIAM PENN PLZ
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2150
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:919-313-1276
Practice Address - Street 1:100 KELLIE DR
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-9444
Practice Address - Country:US
Practice Address - Phone:919-220-5255
Practice Address - Fax:919-313-1276
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004050363A00000X
MT299363A00000X
NC0010-10604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-10604OtherNORTH CAROLINA MEDICAL BOARD
MT438974Medicaid
WY119180200Medicaid
MT000900843OtherBLUECROSS BLUESHIELD
MT970024193OtherRR MEDICARE
WA2019929Medicaid
MT000900843OtherBLUECROSS BLUESHIELD
MT0500560001Medicare NSC