Provider Demographics
NPI:1598008112
Name:BLACKMAN, KYLE ROSS (ATC)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:ROSS
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21300 REDSKIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-6100
Mailing Address - Country:US
Mailing Address - Phone:703-726-7000
Mailing Address - Fax:
Practice Address - Street 1:21300 REDSKIN PARK DR
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6100
Practice Address - Country:US
Practice Address - Phone:703-726-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260017422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer