Provider Demographics
NPI:1013346410
Name:BLYTHE, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BLYTHE
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 1:2102 IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-7913
Mailing Address - Country:US
Mailing Address - Phone:775-389-5777
Mailing Address - Fax:775-360-3602
Practice Address - Street 1:2102 IDAHO ST
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801
Practice Address - Country:US
Practice Address - Phone:775-389-5777
Practice Address - Fax:775-360-3602
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8797967-1206363A00000X
UT8797967-8906363A00000X
NVPA1983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1013346410Medicaid