Provider Demographics
NPI:1811217409
Name:BLACKWELL, BLEN D (PA-C)
Entity Type:Individual
Prefix:
First Name:BLEN
Middle Name:D
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 1:3688 VETERANS MEMORIAL DR.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401
Mailing Address - Country:US
Mailing Address - Phone:601-554-7400
Mailing Address - Fax:601-554-7499
Practice Address - Street 1:3688 VETERANS MEMORIAL DR.
Practice Address - Street 2:SUITE 200
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-554-7400
Practice Address - Fax:601-554-7499
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant