Provider Demographics
NPI:1316050602
Name:BLACKNER, GREGARY M (MD)
Entity type:Individual
Prefix:
First Name:GREGARY
Middle Name:M
Last Name:BLACKNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 721
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-0721
Mailing Address - Country:US
Mailing Address - Phone:801-682-8190
Mailing Address - Fax:801-214-1875
Practice Address - Street 1:1617 SUMMIT LAKE SHORE RD NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-9437
Practice Address - Country:US
Practice Address - Phone:801-682-8190
Practice Address - Fax:801-214-1875
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8455420Medicaid
WA8455420Medicaid
WA8455420Medicaid