Provider Demographics
NPI:1487641536
Name:BLACKMON, SHAWNA C (PA)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:C
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:C
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:3414 GOLDEN RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8336
Mailing Address - Country:US
Mailing Address - Phone:903-939-7500
Mailing Address - Fax:903-939-7728
Practice Address - Street 1:3816 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2011
Practice Address - Country:US
Practice Address - Phone:903-939-7500
Practice Address - Fax:903-939-7728
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04131363AS0400X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00743048OtherRAILROAD MEDICARE
TX8360NDOtherBLUE CROSS BLUE SHIELD
TX206265503Medicaid
TX206265502Medicaid
TX206265504Medicaid
TX206265501Medicaid
TX8Y8693OtherBCBS
TX8Y8693OtherBCBS
TX8L15277Medicare PIN
TX8360NDOtherBLUE CROSS BLUE SHIELD
TX206265501Medicaid
TX206265502Medicaid
TXTXB151178Medicare PIN