Provider Demographics
NPI:1710762091
Name:BLAIR, KEITH LOREN (APRN-CNP)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:LOREN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4404
Mailing Address - Country:US
Mailing Address - Phone:405-564-4107
Mailing Address - Fax:
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4404
Practice Address - Country:US
Practice Address - Phone:209-576-3525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026892363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner