Provider Demographics
NPI:1265413264
Name:BLACKMON, ALICE T (PNP-C)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:T
Last Name:BLACKMON
Suffix:
Gender:
Credentials:PNP-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:T
Other - Last Name:BLACKMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PNP-C
Mailing Address - Street 1:7323 MARBACH RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1905
Mailing Address - Country:US
Mailing Address - Phone:210-645-4305
Mailing Address - Fax:210-673-1850
Practice Address - Street 1:7323 MARBACH RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1905
Practice Address - Country:US
Practice Address - Phone:210-645-4305
Practice Address - Fax:210-673-1850
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP108315363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP108315OtherLICENSE
TX1508813494OtherGROUP PRACTICE/BILLING NPI#
TX193200000XOtherGRP TAXONOMY
TX363LP0200XOtherINDIVIDUAL TAXONOMY
TX1265413264OtherALICE BLACKMON, PNP-C NPI#