Provider Demographics
NPI:1336663863
Name:BLAIR, ELIJAH (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 MINISTRY PKWY
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-5220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 MINISTRY PKWY
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5220
Practice Address - Country:US
Practice Address - Phone:715-393-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4114-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant