Provider Demographics
NPI:1164490801
Name:BLACKBURN, JOHN STEPHEN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:STEPHEN
Last Name:BLACKBURN
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:PO BOX 1637
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-1637
Mailing Address - Country:US
Mailing Address - Phone:803-407-5266
Mailing Address - Fax:
Practice Address - Street 1:7210G BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-7972
Practice Address - Country:US
Practice Address - Phone:803-407-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11770367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11770OtherAPN
TN60552OtherRN