Provider Demographics
NPI:1841269313
Name:BLACKSHEAR, KIRSTINE A (PA-C)
Entity type:Individual
Prefix:
First Name:KIRSTINE
Middle Name:A
Last Name:BLACKSHEAR
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 1:9250 N 3RD ST
Mailing Address - Street 2:SUITE 4010
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2437
Mailing Address - Country:US
Mailing Address - Phone:602-633-3848
Mailing Address - Fax:602-633-3841
Practice Address - Street 1:1209 N MILLER RD
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-1043
Practice Address - Country:US
Practice Address - Phone:623-386-5785
Practice Address - Fax:623-386-6673
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2967363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMB1101942OtherDEA
AZQ42534Medicare UPIN
AZMB1101942OtherDEA