Provider Demographics
NPI:1851660336
Name:BLACK, ALLIE CHRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALLIE
Middle Name:CHRISTINE
Last Name:BLACK
Suffix:
Gender:F
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 1:3051 E UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7902
Mailing Address - Country:US
Mailing Address - Phone:432-362-4376
Mailing Address - Fax:432-362-6308
Practice Address - Street 1:3051 E UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7902
Practice Address - Country:US
Practice Address - Phone:432-362-4376
Practice Address - Fax:432-362-6308
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07554363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant