Provider Demographics
NPI:1750510855
Name:BLAIR, LAUREL J (MD)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:J
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 S EASTERN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-3908
Mailing Address - Country:US
Mailing Address - Phone:702-914-2420
Mailing Address - Fax:702-914-6653
Practice Address - Street 1:10001 S EASTERN AVE STE 201
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3908
Practice Address - Country:US
Practice Address - Phone:702-914-2420
Practice Address - Fax:702-914-6653
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-02433208600000X
PAMT194435208600000X
NV16517208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD443811OtherPA LICENSE
SCNC2131Medicaid
NC2013-02433OtherNC LICENSE
NC1750510855Medicaid
PAMT194435OtherMEDICAL LICENSE NUMBER
PAMD443811OtherPA LICENSE
NC2013-02433OtherNC LICENSE