Provider Demographics
NPI:1952863003
Name:BLACKHURST, NATHAN (PA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BLACKHURST
Suffix:
Gender:M
Credentials:PA
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 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:485 S DOBSON RD STE 110
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5600
Practice Address - Country:US
Practice Address - Phone:480-728-4470
Practice Address - Fax:480-728-4499
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
AZ7553363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ250782Medicaid