Provider Demographics
NPI:1124550983
Name:BLACKWOOD, TECSHANA NICOLA (PA)
Entity Type:Individual
Prefix:MRS
First Name:TECSHANA
Middle Name:NICOLA
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W 39TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018
Mailing Address - Country:US
Mailing Address - Phone:347-523-1091
Mailing Address - Fax:203-624-4301
Practice Address - Street 1:1 LONG WHARF DR STE 212
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5593
Practice Address - Country:US
Practice Address - Phone:203-624-4208
Practice Address - Fax:203-624-4301
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020717146D00000X
CT0038009363A00000X
CT3809363AM0700X
NY020717-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical