MEDICARE: MR. WALTER DAVID BLANKENSHIP P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MB1192183	TN
2	363A00000X	Physician Assistant	1171	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00232697	OTHER	TN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	4099853	OTHER	TN	BLUE CROSS

General Provider Information

NPI Number	:	1528008547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WALTER DAVID BLANKENSHIP P.A.

Provider Business Mailing Address
First Line	:	6933 LARK LN
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37919-5929
Country	:	US
Telephone Number	:	865-776-0800
Fax Number	:

Provider Business Practice Location Address
First Line	:	9135 MIDDLEBROOK PIKE
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37923-1425
Country	:	US
Telephone Number	:	865-558-3038
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	02/14/2023

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