Provider Demographics
NPI:1437528148
Name:BLAIR, BRADLEY JACOB (BSN, RN, CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JACOB
Last Name:BLAIR
Suffix:
Gender:M
Credentials:BSN, RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 24776
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-4776
Mailing Address - Country:US
Mailing Address - Phone:877-288-1799
Mailing Address - Fax:855-917-2023
Practice Address - Street 1:907 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5015
Practice Address - Country:US
Practice Address - Phone:865-380-9070
Practice Address - Fax:865-380-9093
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN180244367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I434709Medicare PIN