Basic Information
| Provider Information | |||||||||
| NPI: | 1699907527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLALOCK | ||||||||
| FirstName: | CIMARON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NEEL | ||||||||
| OtherFirstName: | CIMARON | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1309 NORTHGATE CIRCLE | ||||||||
| Address2: | |||||||||
| City: | HIXSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522735422 | ||||||||
| FaxNumber: | 3522735927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2009 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9105054 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA9105054 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.