Michaela Rose Blackwell, PA-C
Physician Assistant in Rockford, IL. Individual provider (NPI-1).
NPI number1407553019
StatusActive
Last updated in NPPESNov 1, 2024
Details
- NPI
- 1407553019
- Entity type
- Individual (NPI-1)
- Name
- Michaela Rose Blackwell
- Credential
- PA-C
- Sex
- Female
- Sole proprietor
- No
- Enumeration date
- Feb 14, 2023
- Certification date
- Nov 1, 2024
- Last updated
- Nov 1, 2024
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 363A00000X | Physician Assistant | 085010688 | IL | Yes |
Practice location
5875 E Riverside BlvdRockford, IL 61114-4937
Phone 815-398-9491
Mailing address
Po Box 735263Chicago, IL 60673-5263
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