Basic Information
| Provider Information | |||||||||
| NPI: | 1215153127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKSTOCK | ||||||||
| FirstName: | DINA | ||||||||
| MiddleName: | DAWSON | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2489 | ||||||||
| Address2: | |||||||||
| City: | FOREST | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245516489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343821139 | ||||||||
| FaxNumber: | 4345255748 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 AMELON SQ | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245725981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349291095 | ||||||||
| FaxNumber: | 4349291098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110001206 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00451415 | 01 | MEDICARE RAILROAD PROVIDER NUMBER | OTHER |