Provider Demographics
NPI:1275176604
Name:BLACKBURN, ILEANA PANEBIANCO (PA-C)
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:PANEBIANCO
Last Name:BLACKBURN
Suffix:
Gender:F
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 1:3449 MENOHER BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-5503
Mailing Address - Country:US
Mailing Address - Phone:814-248-9792
Mailing Address - Fax:
Practice Address - Street 1:1020 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4109
Practice Address - Country:US
Practice Address - Phone:814-534-9132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant