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NPI Code Detail

MEDICARE: MR. GARY BLACKBURN RN

MEDICARE: MR. GARY BLACKBURN RN
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
1163W00000XRegistered Nurse528477NY

General Provider Information

NPI Number : 1548125917
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. GARY BLACKBURN RN
Provider Business Mailing Address
First Line : 800 RED MILLS RD
Second Line :
City : WALLKILL
State : NY
Zip : 12589-3220
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 800 RED MILLS RD
Second Line :
City : WALLKILL
State : NY
Zip : 12589-3220
Country : US
Telephone Number : 914-217-7592
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/18/2025
Last Update Date : 12/18/2025

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