Basic Information
| Provider Information | |||||||||
| NPI: | 1558739003 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLALOCK | ||||||||
| FirstName: | GARRETT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2081 CHULA BROOKFIELD RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317942662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2294024430 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 18TH ST E | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293536051 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2015 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 7724 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.