Healthcare Provider Details

I. General information

NPI: 1639134679
Provider Name (Legal Business Name): MICHAEL LOWELL BLACKBURN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 YORKSHIRE MEDICAL PARK
LEXINGTON KY
40509-1886
US

IV. Provider business mailing address

3480 YORKSHIRE MEDICAL PARK
LEXINGTON KY
40509-1886
US

V. Phone/Fax

Practice location:
  • Phone: 859-263-5140
  • Fax:
Mailing address:
  • Phone: 859-263-5140
  • Fax: 859-263-5141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA934
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA934
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: