Provider Demographics
NPI:1679735138
Name:BLACK, DARRYLL W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DARRYLL
Middle Name:W
Last Name:BLACK
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 1:88 MDG
Mailing Address - Street 2:4881 SUGAR MAPLE DR
Mailing Address - City:WRIGHT-PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-257-6569
Mailing Address - Fax:
Practice Address - Street 1:88 MDG
Practice Address - Street 2:4881 SUGAR MAPLE DR
Practice Address - City:WRIGHT-PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-6569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002023A363A00000X
PAMA053346363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0171202Medicaid
INOPRMedicaid
OH0171202Medicaid
IN259370155Medicare PIN