Basic Information
| Provider Information | |||||||||
| NPI: | 1841269313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKSHEAR | ||||||||
| FirstName: | KIRSTINE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9250 N 3RD ST | ||||||||
| Address2: | SUITE 4010 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026333848 | ||||||||
| FaxNumber: | 6026333841 | ||||||||
| Practice Location | |||||||||
| Address1: | 1209 N MILLER RD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853261043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233865785 | ||||||||
| FaxNumber: | 6233866673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 12/16/2010 | ||||||||
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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 | 363AM0700X | 2967 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | MB1101942 | 01 | AZ | DEA | OTHER |