Provider Demographics
NPI:1023432093
Name:BLACKBURN, MEGAN NOEL (PA-C)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:NOEL
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:NOEL
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:ATTN: MEGAN BLACKBURN
Mailing Address - Street 2:PO BOX 449
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 PIKE ST STE 2
Practice Address - Street 2:PHYSICIANS CARE EXPRESS - MARIETTA
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3507
Practice Address - Country:US
Practice Address - Phone:740-373-3960
Practice Address - Fax:740-373-3965
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPENDING363AM0700X
WV1699363AM0700X
OH50.006761RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1699OtherLICENSE