Individual
LISA ANN BLACKLIDGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
206 2ND ST E, BRADENTON, FL 34208-1042
(941) 746-5111
(941) 745-7233
Mailing address
367 S. GULPH RD, ATT IPM CREDENTIALING, KING OF PRUSSIA, PA 19406-3121
(775) 356-9393
(775) 356-5590
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
PA9101122
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
015120400
—
FL
01
—
970020641
RAILROAD MEDICARE
—
Enumeration date
04/07/2006
Last updated
07/21/2022
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