Provider Demographics
NPI:1790883684
Name:BLAIR, SUSAN (FNP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11801 SOUTH FWY
Mailing Address - Street 2:SUITE 338
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7021
Mailing Address - Country:US
Mailing Address - Phone:817-568-5485
Mailing Address - Fax:817-568-5434
Practice Address - Street 1:11801 SOUTH FWY
Practice Address - Street 2:SUITE 338
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7021
Practice Address - Country:US
Practice Address - Phone:817-568-5485
Practice Address - Fax:817-568-5434
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103294803Medicaid
TX103294801Medicaid
TX8L5926Medicare PIN
TXS64198Medicare UPIN
TX8935B9Medicare PIN
TX103294803Medicaid