1005 BOULDER DR
GRAY, GA 31032 US PECOS Enrolled
Overview
Wyatt Kenny Blake is a Family Medicine Physician in the GRAY area. Wyatt Kenny Blake primary office location is at 1005 BOULDER DR and new patients are welcome to contact this healthcare provider for an appointment. The NPI number is 1548263064 and the information was updated approximately 5 years ago.
We have not detected any Exclusions tied directly to this NPI.
Accepts Medicare Assignment: Unknown
Is sole proprietor: NO
Participates in PECOS: YES (See any PECOS details below)
Contact Information
| License Number | State |
|---|---|
| 047702 | GA |
| Type/Issuer | Identifier | State |
|---|---|---|
| MEDICAID | 000909114E | GA |
| BCBS OF GEORGIA | 843785 | GA |
| RAILROAD MEDICARE | 080176614 | GA |
| GA LICENSE | 047702 | GA |
| Taxonomy | State | Primary? |
|---|---|---|
| Family Medicine Physician - Taxonomy Code 207Q00000X | GA | Y |
PECOS Details:
| Participates in PECOS: | YES |
| PECOS Individual Enrollment ID: | |
| PECOS Individual PAC ID: | |
| Eligible to order/refer Part B Clinical Laboratory and Imaging | Yes |
| Eligible to order/refer Durable Medical Equipment (DME) | Yes |
| Eligible to order/refer Home Health Agency (HHA) | Yes |
| Eligible to order/refer Power Mobility Devices (PMD) | Yes |
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