Provider Demographics
NPI:1891776852
Name:BLOUNT, ALFRED NICHOLSON JR (CRNA)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:NICHOLSON
Last Name:BLOUNT
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20875-1510
Mailing Address - Country:US
Mailing Address - Phone:301-515-4222
Mailing Address - Fax:301-515-4153
Practice Address - Street 1:20201 CENTURY BLVD
Practice Address - Street 2:SUITE 480
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-1113
Practice Address - Country:US
Practice Address - Phone:301-515-4222
Practice Address - Fax:301-515-4153
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN088820367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1154903Medicaid
LA1154903Medicaid