Basic Information
| Provider Information | |||||||||
| NPI: | 1588841621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKLER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAYMIRE | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | RYAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2001 S SHIELDS ST | ||||||||
| Address2: | BUILDING I | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805261827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702215255 | ||||||||
| FaxNumber: | 9702215206 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 S SHIELDS ST | ||||||||
| Address2: | BUILDING I | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805261827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702215255 | ||||||||
| FaxNumber: | 9702215206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 07/18/2016 | ||||||||
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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 | 2546 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA-795 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0812 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 807782300 | 05 | ID | MEDICAID |