Provider Demographics
NPI:1780348219
Name:BLUE, THERESA (PA-C)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:BLUE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 NW 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34475-3400
Mailing Address - Country:US
Mailing Address - Phone:352-216-9222
Mailing Address - Fax:352-629-5907
Practice Address - Street 1:3801 NW 20TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34475-3400
Practice Address - Country:US
Practice Address - Phone:352-216-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-31
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117564363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical