Provider Demographics
NPI:1578689220
Name:BLAIR, TRACY LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:BLAIR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8107 STONEGATE DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-7191
Mailing Address - Country:US
Mailing Address - Phone:815-469-0320
Mailing Address - Fax:
Practice Address - Street 1:8107 STONEGATE DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7191
Practice Address - Country:US
Practice Address - Phone:815-469-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28164567A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL312745064Medicaid
IN200859590Medicaid
IN000000518200OtherANTHEM BCBS
IN200859590Medicaid