Provider Demographics
NPI:1346335189
Name:BLAIR, KATHLEEN S (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:BLAIR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:SUZANNE
Other - Last Name:SUCKOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1401 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5183
Mailing Address - Country:US
Mailing Address - Phone:406-731-8888
Mailing Address - Fax:406-731-8876
Practice Address - Street 1:1401 25TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5183
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8876
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4193207R00000X
MT11368207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ945363Medicaid
AZ945363Medicaid
I35162Medicare UPIN