Provider Demographics
NPI:1831103472
Name:BLACKMON, E. ABIGAIL WALTERS (MD)
Entity Type:Individual
Prefix:
First Name:E. ABIGAIL
Middle Name:WALTERS
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:WALTERS
Other - Last Name:BLACKMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7714 CONNER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-3559
Mailing Address - Country:US
Mailing Address - Phone:865-212-6350
Mailing Address - Fax:865-212-6350
Practice Address - Street 1:7714 CONNER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3559
Practice Address - Country:US
Practice Address - Phone:865-212-6350
Practice Address - Fax:865-212-6350
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3053208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2Medicaid
TN2Medicaid