Provider Demographics
NPI:1295820298
Name:BLACKSTOCK, DARYLE MARC (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:DARYLE
Middle Name:MARC
Last Name:BLACKSTOCK
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:622 W 168TH ST
Mailing Address - Street 2:PH 14, RM 104
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-7771
Mailing Address - Fax:212-342-5307
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:PH 14, RM 104
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-7771
Practice Address - Fax:212-342-5307
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2015-07-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY006279-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP07765Medicare UPIN