MEDICARE: MRS. KIMBERLEE BANKS BLAYLOCK P.A.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0001-04141	NC
2	363A00000X	Physician Assistant	104141	NC

General Provider Information

NPI Number	:	1225024029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLEE BANKS BLAYLOCK P.A.-C

Provider Business Mailing Address
First Line	:	MEDICAL CENTER BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-0001
Country	:	US
Telephone Number	:	336-716-8200
Fax Number	:	336-716-9841

Provider Business Practice Location Address
First Line	:	131 MILLER ST
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-2508
Country	:	US
Telephone Number	:	336-716-8200
Fax Number	:	336-716-9841

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	01/30/2026

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