Provider Demographics
NPI:1619042009
Name:BLACKWELL, HAYLEY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:HAYLEY
Middle Name:
Last Name:BLACKWELL
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 1:201 E ARIZONA AVE
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79556-7119
Mailing Address - Country:US
Mailing Address - Phone:325-235-8641
Mailing Address - Fax:325-235-5925
Practice Address - Street 1:201 E ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556-7119
Practice Address - Country:US
Practice Address - Phone:325-235-8641
Practice Address - Fax:325-235-5925
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
TXPA05094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194634501Medicaid