Provider Demographics
NPI:1366891830
Name:BLANKENSHIP, EMMITT MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:EMMITT
Middle Name:MATTHEW
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:P O BOX 1000 DEPT 960
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-763-0200
Mailing Address - Fax:901-260-1704
Practice Address - Street 1:1325 EASTMORELAND AVE STE 365
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7542
Practice Address - Country:US
Practice Address - Phone:901-272-6030
Practice Address - Fax:901-516-8450
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2017-12-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDC06210363A00000X
TN3404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant