Provider Demographics
NPI:1093051989
Name:BLACKWOOD, CARL C (CRNA)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:C
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 LILLIBRIDGE ST APT 10
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-3543
Mailing Address - Country:US
Mailing Address - Phone:607-349-9774
Mailing Address - Fax:
Practice Address - Street 1:5701 LILLIBRIDGE ST APT 10
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-3543
Practice Address - Country:US
Practice Address - Phone:607-349-9774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.005251367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered