Provider Demographics
NPI:1316410665
Name:BLACKLEDGE, AMBER R (PA-C)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:R
Last Name:BLACKLEDGE
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:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:KOPPEL
Mailing Address - State:PA
Mailing Address - Zip Code:16136-0479
Mailing Address - Country:US
Mailing Address - Phone:724-312-0429
Mailing Address - Fax:
Practice Address - Street 1:4 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-8482
Practice Address - Country:US
Practice Address - Phone:304-473-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060316363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant