MEDICARE: MS. ELLEN LOUISE BLACKMORE PA-C

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	363AM0700X	Medical Physician Assistant	397	CO

General Provider Information

NPI Number	:	1588845168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELLEN LOUISE BLACKMORE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 1228
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80306-1228
Country	:	US
Telephone Number	:	303-473-4546
Fax Number	:

Provider Business Practice Location Address
First Line	:	10900 SMITH RD
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80239-3262
Country	:	US
Telephone Number	:	303-307-2320
Fax Number	:

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

Provider Enumeration Date	:	11/23/2007
Last Update Date	:	11/23/2007

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