Provider Demographics
NPI:1629054705
Name:BLACKWELL, MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
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 1:9700 EL CAMINO REAL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422
Mailing Address - Country:US
Mailing Address - Phone:805-461-9000
Mailing Address - Fax:805-461-9001
Practice Address - Street 1:9700 EL CAMINO REAL
Practice Address - Street 2:SUITE 100
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422
Practice Address - Country:US
Practice Address - Phone:805-461-9000
Practice Address - Fax:805-461-9001
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA173310Medicaid
CAPA173310Medicaid
CA00PA173310Medicare ID - Type Unspecified