Provider Demographics
NPI:1437593209
Name:GERHART, BLAED JACOB (PA-C)
Entity type:Individual
Prefix:
First Name:BLAED
Middle Name:JACOB
Last Name:GERHART
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSE 490 P.O. BOX 9095
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96538
Mailing Address - Country:US
Mailing Address - Phone:671-344-9679
Mailing Address - Fax:671-344-9305
Practice Address - Street 1:1 FARENHOLT ST
Practice Address - Street 2:BLDG K-1
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96538
Practice Address - Country:US
Practice Address - Phone:671-344-9679
Practice Address - Fax:671-344-9305
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055993363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant