Provider Demographics
NPI:1093582827
Name:BLACKWOOD, WAYNE EVERTHAN
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:EVERTHAN
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 E JOPPA RD STE 201
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-3045
Mailing Address - Country:US
Mailing Address - Phone:443-635-1423
Mailing Address - Fax:410-882-0790
Practice Address - Street 1:2914 E JOPPA RD STE 201
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-3045
Practice Address - Country:US
Practice Address - Phone:443-635-1423
Practice Address - Fax:410-882-0970
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician