Individual
GREGORY ANDREW BLACKMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC, ATC
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
2000020732
—
363A00000X
Physician Assistant
1174263
—
363AS0400X
Surgical Physician Assistant
Primary
PA100402
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1174263
NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
—
01
—
2000020732
BOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER
—
01
—
MPA10000541
CONTROLLED
MA
01
—
MSC000004A
PRESCRIBE
MA
01
—
PA100402
LICENSE
MA
Enumeration date
08/28/2016
Last updated
12/14/2025
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