Provider Demographics
NPI:1699907527
Name:BLALOCK, CIMARON R (PAC)
Entity type:Individual
Prefix:
First Name:CIMARON
Middle Name:R
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CIMARON
Other - Middle Name:
Other - Last Name:NEEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1309 NORTHGATE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343
Mailing Address - Country:US
Mailing Address - Phone:352-273-7770
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-5422
Practice Address - Fax:352-273-5927
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105054363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCT600ZMedicare PIN