Provider Demographics
NPI:1245287416
Name:BLELLOCH, LAWRENCE (PA)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:BLELLOCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6512 SIX FORKS RD
Mailing Address - Street 2:SUITE 102B
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6561
Mailing Address - Country:US
Mailing Address - Phone:919-870-8845
Mailing Address - Fax:919-870-8845
Practice Address - Street 1:6512 SIX FORKS RD
Practice Address - Street 2:SUITE 102B
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6561
Practice Address - Country:US
Practice Address - Phone:919-870-8845
Practice Address - Fax:919-870-8845
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC101803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS62989Medicare UPIN