Provider Demographics
NPI:1306986294
Name:FAWCETT, BLYTHE E (PA)
Entity type:Individual
Prefix:
First Name:BLYTHE
Middle Name:E
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LANSING ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1983
Mailing Address - Country:US
Mailing Address - Phone:315-567-0455
Mailing Address - Fax:315-253-1795
Practice Address - Street 1:37 W GARDEN ST STE 105
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021
Practice Address - Country:US
Practice Address - Phone:315-252-0000
Practice Address - Fax:315-252-0070
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009708363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03444915Medicaid
Q20340Medicare UPIN
NYJ400061821Medicare PIN