Individual
GREGARY M BLACKNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1617 SUMMIT LAKE SHORE RD NW, OLYMPIA, WA 98502-9437
(801) 682-8190
(801) 214-1875
Mailing address
PO BOX 721, KAYSVILLE, UT 84037-0721
(801) 682-8190
(801) 214-1875
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD00026210
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8455420
—
WA
Enumeration date
08/17/2006
Last updated
05/25/2021
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