Provider Demographics
NPI:1306063946
Name:BLACKMAN, KEN (NMD)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3953 E PARADISE FALLS DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6688
Mailing Address - Country:US
Mailing Address - Phone:520-323-0401
Mailing Address - Fax:520-319-9792
Practice Address - Street 1:3953 E PARADISE FALLS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6688
Practice Address - Country:US
Practice Address - Phone:520-323-0401
Practice Address - Fax:520-319-9792
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ360175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBB6811586OtherDEA