Provider Demographics
NPI:1548669823
Name:BLACKBURN, BRENT (MD, AG-ACNP, FNP)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MD, AG-ACNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 U OF A WAY
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1419
Mailing Address - Country:US
Mailing Address - Phone:870-779-6000
Mailing Address - Fax:
Practice Address - Street 1:3417 U OF A WAY
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1419
Practice Address - Country:US
Practice Address - Phone:870-779-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004186363LA2100X
ARAK3349289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care