Provider Demographics
NPI:1134698921
Name:BLACKMAN, REGINALD KARL
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:KARL
Last Name:BLACKMAN
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 1:3800 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-1109
Mailing Address - Country:US
Mailing Address - Phone:253-304-7753
Mailing Address - Fax:
Practice Address - Street 1:5929 WESTGATE BLVD STE A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2567
Practice Address - Country:US
Practice Address - Phone:253-503-0226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist