Provider Demographics
NPI:1417661885
Name:BLAIR, MATTHEW MICHAEL (PA-S)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:BLAIR
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5160 W 86TH PL
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-1608
Mailing Address - Country:US
Mailing Address - Phone:219-213-5668
Mailing Address - Fax:
Practice Address - Street 1:5160 W 86TH PL
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1608
Practice Address - Country:US
Practice Address - Phone:219-213-5668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant