Provider Demographics
NPI:1316297740
Name:BLACKBURN, JOSEPH KAY
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:KAY
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 ELM HILL PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214-3108
Mailing Address - Country:US
Mailing Address - Phone:615-425-4200
Mailing Address - Fax:615-425-4268
Practice Address - Street 1:15510 W BELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3436
Practice Address - Country:US
Practice Address - Phone:480-717-4903
Practice Address - Fax:480-717-4904
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant