Provider Demographics
NPI:1386633121
Name:CARMICHAEL, BLAINE PHILLIP (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:PHILLIP
Last Name:CARMICHAEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1045 CENTRAL PARKWAY NORTH
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-5024
Mailing Address - Country:US
Mailing Address - Phone:210-541-4500
Mailing Address - Fax:210-541-4508
Practice Address - Street 1:408 NAVARRO ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2502
Practice Address - Country:US
Practice Address - Phone:210-272-1741
Practice Address - Fax:210-272-1747
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA00009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB103796Medicare PIN