Provider Demographics
NPI:1508370453
Name:BLAIR, NUTTA-ON (PT, PHD)
Entity Type:Individual
Prefix:DR
First Name:NUTTA-ON
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PT, PHD
Other - Prefix:
Other - First Name:NUTTA-ON
Other - Middle Name:
Other - Last Name:PROMJUNYAKUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, PHD
Mailing Address - Street 1:315 ROLLING MIST CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4405
Mailing Address - Country:US
Mailing Address - Phone:414-324-1176
Mailing Address - Fax:
Practice Address - Street 1:6475 JIMMY CARTER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1734
Practice Address - Country:US
Practice Address - Phone:770-242-7744
Practice Address - Fax:770-368-0164
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.00143852251N0400X, 2251P0200X
GAPT0132222251P0200X, 2251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics