Provider Demographics
NPI:1801862339
Name:BLACK, DONALD ALLEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:ALLEN
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 1:1000 HIGHWAY 76
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8405
Mailing Address - Country:US
Mailing Address - Phone:931-245-1150
Mailing Address - Fax:
Practice Address - Street 1:1000 HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8405
Practice Address - Country:US
Practice Address - Phone:931-245-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA038363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYVAD000Medicare UPIN