Basic Information
| Provider Information | |||||||||
| NPI: | 1649380049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95970 | ||||||||
| Address2: | |||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840950970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013529500 | ||||||||
| FaxNumber: | 8013529502 | ||||||||
| Practice Location | |||||||||
| Address1: | 8849 S REDWOOD RD | ||||||||
| Address2: | STE E-121 | ||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840885619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015691999 | ||||||||
| FaxNumber: | 8015692001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3458 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 8983610-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.