Provider Demographics
NPI:1912994260
Name:BLACKBURN, AMANDA J (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:J
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:J
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0690
Mailing Address - Country:US
Mailing Address - Phone:606-464-0151
Mailing Address - Fax:606-464-0152
Practice Address - Street 1:1484 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-6555
Practice Address - Country:US
Practice Address - Phone:606-666-9950
Practice Address - Fax:606-666-9136
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA804363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY950041230Medicaid
KYQ04138Medicare UPIN