Provider Demographics
NPI:1093828519
Name:BLACKBURN, KAREN N (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:N
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:N
Other - Last Name:DINKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9667
Practice Address - Street 1:9211 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2900
Practice Address - Country:US
Practice Address - Phone:316-609-4400
Practice Address - Fax:316-634-4040
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501125363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
003719060OtherMEDICARE
KS200620270AMedicaid