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General NPI Number Information
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NPI Number | 1669468385
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Entity Type | Individual
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Provider Name | BLYTHE D WALTERSDORF P.A.
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Gender | Female
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Dates
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Enumeration Date | 09/27/2005
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Last Update Date | 07/01/2011
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Provider Practice Location Address
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Address Line | 1610 W TOWNLINE ST SUITE 1
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City | CRESTON
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State | IA
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Zip | 50801-1066
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Country | US
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Telephone | 641-782-2131
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Fax | 641-782-6425
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Provider Business Mailing Address
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Address Line | 1610 W TOWNLINE ST SUITE 1
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City | CRESTON
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State | IA
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Zip | 50801-1066
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Country | US
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Telephone | 641-782-2131
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Fax | 641-782-6425
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 001293
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License Number State | IA
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