Provider Demographics
NPI:1447589783
Name:BLAIR, RYAN R
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:R
Last Name:BLAIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 WORCESTER ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-3744
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:339-686-2561
Practice Address - Street 1:200 S EXECUTIVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4216
Practice Address - Country:US
Practice Address - Phone:888-964-6681
Practice Address - Fax:888-662-0859
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1259-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447589783Medicaid