MEDICARE: KRISTA BLACKSTONE

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

General Provider Information

NPI Number	:	1073972741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTA BLACKSTONE

Provider Business Mailing Address
First Line	:	9414 WAH LO HI DR
Second Line	:
City	:	CLARKSTON
State	:	MI
Zip	:	48348-3276
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2590 S ADAMS RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-5508
Country	:	US
Telephone Number	:	248-810-9274
Fax Number	:

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

Provider Enumeration Date	:	02/23/2016
Last Update Date	:	09/24/2023

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Directions to “ KRISTA BLACKSTONE ” Practice Location

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