Provider Demographics
NPI:1790569408
Name:BLACKBURN, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 524
Mailing Address - Street 2:
Mailing Address - City:BEULAVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28518-0524
Mailing Address - Country:US
Mailing Address - Phone:910-372-2899
Mailing Address - Fax:
Practice Address - Street 1:1545 ORCHARD VILLAS AVE
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-4338
Practice Address - Country:US
Practice Address - Phone:919-684-2445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist