Provider Demographics
NPI:1356897581
Name:BLACKMAN, GREGORY ANDREW (PAC, ATC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ANDREW
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:PAC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 GREEN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1377
Mailing Address - Country:US
Mailing Address - Phone:978-632-0800
Mailing Address - Fax:978-623-0833
Practice Address - Street 1:250 GREEN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1396
Practice Address - Country:US
Practice Address - Phone:978-632-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000207322255A2300X
1174263363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1174263OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
2000020732OtherBOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER