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General NPI Number Information
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NPI Number | 1073925160
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Entity Type | Individual
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Provider Name | WILL RICHARD BLACKMON III PA-C
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Gender | Male
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Dates
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Enumeration Date | 05/23/2014
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Last Update Date | 05/13/2016
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Provider Practice Location Address
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Address Line | 2100 POWELL ST SUITE 920
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City | EMERYVILLE
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State | CA
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Zip | 94608-1826
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Country | US
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Telephone | 925-939-5800
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2844
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City | BERKELEY
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State | CA
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Zip | 94702-0844
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 51619
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License Number State | CA
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