Provider Demographics
NPI:1861530156
Name:BLALOCK, CHARLIE S (CRNA)
Entity type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:S
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50667
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79159-0667
Mailing Address - Country:US
Mailing Address - Phone:800-480-1819
Mailing Address - Fax:817-334-0235
Practice Address - Street 1:4916 OVERTON PLZ
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4415
Practice Address - Country:US
Practice Address - Phone:800-480-1819
Practice Address - Fax:817-334-0235
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX668515367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TXPENDINGMedicaid