Provider Demographics
NPI:1407934755
Name:BLAIR, DAVID WILSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILSON
Last Name:BLAIR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2079 SIERRA DR
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-4557
Mailing Address - Country:US
Mailing Address - Phone:775-777-7887
Mailing Address - Fax:
Practice Address - Street 1:515 SHOSHONE CIR
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-5072
Practice Address - Country:US
Practice Address - Phone:775-738-2252
Practice Address - Fax:775-778-3303
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111113-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP38326Medicare UPIN