Provider Demographics
NPI:1487983664
Name:BLACKWELL, KAREN DYER (PA)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:DYER
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:DENISE
Other - Last Name:DYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4500 MEMORIAL DRIVE
Mailing Address - Street 2:MEMORIAL HOSPITAL MEDICAL AFFAIRS
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-257-4644
Mailing Address - Fax:618-257-6946
Practice Address - Street 1:310 N 7 HILLS RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-4111
Practice Address - Country:US
Practice Address - Phone:618-624-6181
Practice Address - Fax:618-624-7172
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005182363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant