Provider Demographics
NPI:1861439648
Name:BLAZER, KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BLAZER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1928 ALCOA HWY STE 209
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1504
Mailing Address - Country:US
Mailing Address - Phone:865-524-2547
Mailing Address - Fax:865-524-0224
Practice Address - Street 1:1928 ALCOA HWY STE 209
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1504
Practice Address - Country:US
Practice Address - Phone:865-524-2547
Practice Address - Fax:865-219-5070
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA955207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1513364Medicaid
TN3661461Medicare ID - Type Unspecified
TNP82581Medicare UPIN