Provider Demographics
NPI:1649380049
Name:BLACKBURN, BENJAMIN W (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:W
Last Name:BLACKBURN
Suffix:
Gender:M
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:PO BOX 95970
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0970
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:8849 S REDWOOD RD
Practice Address - Street 2:STE E-121
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5619
Practice Address - Country:US
Practice Address - Phone:801-569-1999
Practice Address - Fax:801-569-2001
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3458363A00000X
UT8983610-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ110623Medicare PIN
AZQ71200Medicare UPIN