Provider Demographics
NPI:1003554494
Name:BLACKBURN, SCOTT ANTHONY (NP)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANTHONY
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11275 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-3380
Mailing Address - Country:US
Mailing Address - Phone:313-383-7071
Mailing Address - Fax:313-383-7194
Practice Address - Street 1:11275 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-3380
Practice Address - Country:US
Practice Address - Phone:313-383-7071
Practice Address - Fax:313-383-7194
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704326782363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704326782OtherSTATE LICENSE