Healthcare Provider Details

I. General information

NPI: 1972999266
Provider Name (Legal Business Name): PATRICK WAYNE BLACKBURN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 E ARBOR AVE
MESA AZ
85206-6059
US

IV. Provider business mailing address

PO BOX 6423
CHANDLER AZ
85246-6423
US

V. Phone/Fax

Practice location:
  • Phone: 480-981-1326
  • Fax:
Mailing address:
  • Phone: 480-245-6286
  • Fax: 480-398-8070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number59600
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number59600
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number67910
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: