Basic Information
| Provider Information | |||||||||
| NPI: | 1023432093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | NOEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DANIELS | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | NOEL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | ATTN: MEGAN BLACKBURN | ||||||||
| Address2: | PO BOX 449 | ||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 PIKE ST STE 2 | ||||||||
| Address2: | PHYSICIANS CARE EXPRESS - MARIETTA | ||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457503507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403733960 | ||||||||
| FaxNumber: | 7403733965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2014 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PENDING | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 1699 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 50.006761RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1699 | 01 | WV | LICENSE | OTHER |