Healthcare Provider Details

I. General information

NPI: 1184087744
Provider Name (Legal Business Name): CLOYCE ELIZABETH BLAKELY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CLOYCE ELIZABETH NELSON

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE STE 5660
ALBUQUERQUE NM
87106-4920
US

IV. Provider business mailing address

3723 SE 40TH AVE
PORTLAND OR
97202-1710
US

V. Phone/Fax

Practice location:
  • Phone: 505-563-6565
  • Fax:
Mailing address:
  • Phone: 505-818-3818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA175856
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA175856
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2016-0015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: