Provider Demographics
NPI:1184087744
Name:BLAKELY, CLOYCE ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:CLOYCE
Middle Name:ELIZABETH
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CLOYCE
Other - Middle Name:ELIZABETH
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3723 SE 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1710
Mailing Address - Country:US
Mailing Address - Phone:505-818-3818
Mailing Address - Fax:
Practice Address - Street 1:201 CEDAR ST SE STE 5660
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4920
Practice Address - Country:US
Practice Address - Phone:505-563-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA175856363A00000X, 363AS0400X
NMPA2016-0015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical