Basic Information
| Provider Information | |||||||||
| NPI: | 1750337861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 873 HINOTES CT | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | LYNDEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982649043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603189705 | ||||||||
| FaxNumber: | 3603188735 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 SQUALICUM PKWY | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606714402 | ||||||||
| FaxNumber: | 3606719463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00027685 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8925061 | 01 | WA | LABOR & INDUSTRIES (CV) | OTHER | 07780 | 01 | WA | REGENCE BLUESHIELD | OTHER | 1061548 | 05 | WA | MEDICAID | 0128739 | 01 | WA | LABOR & INDUSTRIES (REG) | OTHER |