Provider Demographics
NPI:1184000234
Name:BLAYLOCK, RUBY AMANDA STIPE (PA-C)
Entity type:Individual
Prefix:
First Name:RUBY AMANDA
Middle Name:STIPE
Last Name:BLAYLOCK
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:RUBY
Other - Middle Name:AMANDA
Other - Last Name:STIPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:4205 BEN FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2143
Practice Address - Country:US
Practice Address - Phone:919-477-6900
Practice Address - Fax:919-620-0974
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001006690363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant