Basic Information
| Provider Information | |||||||||
| NPI: | 1508944646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWELDER | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 W BAY DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337702282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275813550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1345 W BAY DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337702282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275813550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 05/15/2014 | ||||||||
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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 | 363AM0700X | PA9101004 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 004858400 | 05 | FL | MEDICAID |