Blake, Wyatt Kenny

Blake, Wyatt Kenny is an individual health care provider with primary practice located at 1005 Boulder Dr , Gray GA 31032. He recently has only one registered license in Allopathic & Osteopathic Physicians / Family Medicine, which is considered as his primary health care specialty. Blake, Wyatt Kenny can be contacted via phone (478) 621-2100.

Contact Information

Primary practice address
1005 Boulder Dr Gray GA 31032
Phone: (478) 621-2100
Fax: (478) 744-0481
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Family Medicine 207Q00000X 047702 Georgia

Profile Details

NPI number 1548263064
LBN Legal business name Blake, Wyatt Kenny
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date May 30th, 2005
Last updated Jul 17th, 2019 - about 7 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1548263064 NPPES
Georgia MEDICAID 000909114E
Georgia Other 843785
Georgia Other 080176614
Georgia Other 047702

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