Provider Demographics
NPI:1114187572
Name:BLAIR, WILLIAM BRENT
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRENT
Last Name:BLAIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1347 S WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-2936
Mailing Address - Country:US
Mailing Address - Phone:307-234-3047
Mailing Address - Fax:307-234-3897
Practice Address - Street 1:1347 S WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-2936
Practice Address - Country:US
Practice Address - Phone:307-234-3047
Practice Address - Fax:307-234-3897
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119089001Medicaid
WY119089001Medicaid