Provider Demographics
NPI:1508944646
Name:BLACKWELDER, REBECCA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:BLACKWELDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 W BAY DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2282
Mailing Address - Country:US
Mailing Address - Phone:727-581-3550
Mailing Address - Fax:
Practice Address - Street 1:1345 W BAY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2282
Practice Address - Country:US
Practice Address - Phone:727-581-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101004363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004858400Medicaid