Healthcare Provider Details

I. General information

NPI: 1013346410
Provider Name (Legal Business Name): MICHAEL BLYTHE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 03/14/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 IDAHO ST
ELKO NV
89801
US

IV. Provider business mailing address

2102 IDAHO ST
ELKO NV
89801-7913
US

V. Phone/Fax

Practice location:
  • Phone: 775-389-5777
  • Fax: 775-360-3602
Mailing address:
  • Phone: 775-389-5777
  • Fax: 775-360-3602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8797967-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8797967-8906
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1983
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: