Provider Demographics
NPI:1649255563
Name:BLAKELY, BARBARA B (PA-C)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:B
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:B
Other - Last Name:ENGLISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE # MC9014
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-267-7414
Practice Address - Fax:616-267-7137
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N38550OtherMEDICARE PTAN
MI0M74460307Medicare PIN
MIP46717Medicare UPIN
MI0M14700 012Medicare PIN