Provider Demographics
NPI:1982772125
Name:BLIVEN, CAROLINE DUPUY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CAROLINE
Middle Name:DUPUY
Last Name:BLIVEN
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 1:300 HOSPITAL RD. EAMC
Mailing Address - Street 2:ATTN: CREDENTIALS
Mailing Address - City:FT. GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:706-787-8176
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL RD.
Practice Address - Street 2:CONNELLY HEALTH CLINIC
Practice Address - City:FT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5650
Practice Address - Country:US
Practice Address - Phone:706-787-1696
Practice Address - Fax:706-787-8176
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD 000Medicare UPIN