Provider Demographics
NPI:1861612525
Name:YORK, BLAKELY M (PA-C)
Entity type:Individual
Prefix:
First Name:BLAKELY
Middle Name:M
Last Name:YORK
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 1:270 HAWTHORNE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2881
Mailing Address - Country:US
Mailing Address - Phone:706-546-5700
Mailing Address - Fax:
Practice Address - Street 1:270 HAWTHORNE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2881
Practice Address - Country:US
Practice Address - Phone:706-546-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005036363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA998687643AMedicaid
GA005036OtherLICENSE
GAQ78508Medicare UPIN
GA998687643AMedicaid