Basic Information
| Provider Information | |||||||||
| NPI: | 1770127185 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWOOD | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | AARON | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8054 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008629980 | ||||||||
| FaxNumber: | 3143621185 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 PROGRESS POINT PKWY | ||||||||
| Address2: | DEPT ANESTHESIOLOGY | ||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633682205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008629980 | ||||||||
| FaxNumber: | 3143621185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2019 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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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 | 367500000X | 2019033779 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 910079212 | 05 | MO | MEDICAID |