Provider Demographics
NPI:1265605372
Name:BLANTON, BRIAN DEWAYNE JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DEWAYNE
Last Name:BLANTON
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3294 NORTH OAK ST. EXT.
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-241-1188
Mailing Address - Fax:229-245-7106
Practice Address - Street 1:3294 NORTH OAK ST. EXT.
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-241-1188
Practice Address - Fax:229-245-7106
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant