Provider Demographics
NPI:1598733958
Name:BLAZER, DAVINA S (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DAVINA
Middle Name:S
Last Name:BLAZER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:DAVINA
Other - Middle Name:S
Other - Last Name:BALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:800 OAK RIDGE TPKE
Mailing Address - Street 2:SUITE A300
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6957
Mailing Address - Country:US
Mailing Address - Phone:865-482-2129
Mailing Address - Fax:865-482-4036
Practice Address - Street 1:800 OAK RIDGE TPKE
Practice Address - Street 2:SUITE A300
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6957
Practice Address - Country:US
Practice Address - Phone:865-482-2129
Practice Address - Fax:865-482-4036
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2007072OtherBLUECROSS OF TENNESSEE ID
P00003758OtherRAILROAD MEDICARE ID
TNP85950Medicare UPIN
TN3661635Medicare PIN