Provider Demographics
NPI:1245249382
Name:BLACKSHER, CAROL D (APRN BC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:D
Last Name:BLACKSHER
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:713 THE HAMPTONS LANE
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5901
Mailing Address - Country:US
Mailing Address - Phone:314-268-6195
Mailing Address - Fax:314-645-6478
Practice Address - Street 1:3535 S JEFFERSON AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3930
Practice Address - Country:US
Practice Address - Phone:314-776-7999
Practice Address - Fax:314-772-2257
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2012-12-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO099601363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427252515Medicaid
Q37862Medicare UPIN
MO824343137Medicare ID - Type Unspecified