Provider Demographics
NPI:1134148638
Name:BLALOCK, WILLIAM TATE (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TATE
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:
Other - Last Name:BLALOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 4000
Mailing Address - Street 2:QUILLEN VETERANS AFFAIRS MEDICAL CENTER
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-4000
Mailing Address - Country:US
Mailing Address - Phone:423-979-3497
Mailing Address - Fax:423-979-2894
Practice Address - Street 1:DOGWOOD AVE
Practice Address - Street 2:QUILLEN VETERANS AFFAIRS MEDICAL CENTER -BLDG 204
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684-4000
Practice Address - Country:US
Practice Address - Phone:423-979-3497
Practice Address - Fax:423-979-2894
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN409363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8923647Medicaid
GA970009000Medicare ID - Type UnspecifiedRAIL ROAD
VA8923647Medicaid
TNS73333Medicare UPIN