Provider Demographics
NPI:1780791749
Name:BLACKBURN, LORI A (PAC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N BELLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-1120
Mailing Address - Country:US
Mailing Address - Phone:423-587-8300
Mailing Address - Fax:423-289-1609
Practice Address - Street 1:305 N BELLWOOD RD
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-1120
Practice Address - Country:US
Practice Address - Phone:423-587-8300
Practice Address - Fax:423-289-1609
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1739363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1521156Medicaid
TN3667050Medicare PIN
TN521155Medicaid