Provider Demographics
NPI:1568086288
Name:BLAKER, WILLIAM GEORGE (MSN)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GEORGE
Last Name:BLAKER
Suffix:
Gender:M
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 CAVALIER DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-9206
Mailing Address - Country:US
Mailing Address - Phone:865-654-8868
Mailing Address - Fax:
Practice Address - Street 1:1551 CAVALIER DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-9206
Practice Address - Country:US
Practice Address - Phone:865-654-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN171293363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health