Provider Demographics
NPI:1679925606
Name:BLANKENSHIP, TYLER RHYSE (PA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:RHYSE
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GRESHAM DR STE 8620
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-395-1600
Mailing Address - Fax:757-625-0433
Practice Address - Street 1:600 GRESHAM DR STE 8620
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-395-1600
Practice Address - Fax:757-625-0433
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10680Medicare PIN