Provider Demographics
NPI:1629047873
Name:BLAIR, GLEN S (CNP)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:S
Last Name:BLAIR
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3510
Mailing Address - Country:US
Mailing Address - Phone:617-825-9660
Mailing Address - Fax:617-288-7898
Practice Address - Street 1:230 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5420
Practice Address - Country:US
Practice Address - Phone:781-431-5255
Practice Address - Fax:781-431-5329
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN157507363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2733OtherBLUE CROSS
MA110018170AMedicaid
MAC318OtherHARVARD PILGRIM
MAP15172Medicare UPIN
MA0375080Medicaid