Provider Demographics
NPI:1922292705
Name:ANDERSON, BLAYNE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAYNE
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
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 1:470 JOHNSON RD STE 210
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-8944
Mailing Address - Country:US
Mailing Address - Phone:412-206-6770
Mailing Address - Fax:724-941-5027
Practice Address - Street 1:470 JOHNSON RD STE 210
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-8944
Practice Address - Country:US
Practice Address - Phone:412-206-6770
Practice Address - Fax:724-941-5027
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053436363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical