Healthcare Provider Details

I. General information

NPI: 1346294139
Provider Name (Legal Business Name): DEBORAH DENISE BLAKELY PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBORAH DENISE BIBBY PA

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-8908
US

IV. Provider business mailing address

PO BOX 751461
CHARLOTTE NC
28275-1461
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2064
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004719
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: