Healthcare Provider Details

I. General information

NPI: 1558340844
Provider Name (Legal Business Name): CLINTON JED BLAINE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 PURDY RD
HUNTINGDON TN
38344-8050
US

IV. Provider business mailing address

3500 PURDY RD
HUNTINGDON TN
38344-8050
US

V. Phone/Fax

Practice location:
  • Phone: 731-986-2536
  • Fax:
Mailing address:
  • Phone: 541-731-4672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA161186
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA892
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: