Provider Demographics
NPI:1952347965
Name:BLACKMON, SHANDA HALEY (MD, MPH)
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:HALEY
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:7200 CAMBRIDGE ST FL 6
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4202
Practice Address - Country:US
Practice Address - Phone:713-798-6376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58299208G00000X
TXL6794208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182618201Medicaid
TX182618204Medicaid
TX8V8608OtherBLUE CROSS BLUE SHIELD
TX8DY873OtherBLUE CROSS BLUE SHIELD
TXP00366710OtherRAILROAD MEDICARE
TXP01098093OtherRR MEDICARE
TX8L14734Medicare PIN
TX8DY873OtherBLUE CROSS BLUE SHIELD
TX8V8608OtherBLUE CROSS BLUE SHIELD