Individual
BLAINE C ETZEL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
100 KELLIE DR, SMITHFIELD, NC 27577-9444
(919) 220-5255
(919) 313-1276
Mailing address
120 WILLIAM PENN PLZ, DURHAM, NC 27704-2150
(919) 220-5255
(919) 313-1276
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0010-10604
NC
363A00000X
Physician Assistant
299
MT
363A00000X
Physician Assistant
PA10004050
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0010-10604
NORTH CAROLINA MEDICAL BOARD
NC
Enumeration date
08/18/2005
Last updated
09/23/2020
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