Provider Demographics
NPI:1891861704
Name:BLINN, GARY A (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:BLINN
Suffix:
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 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-892-5602
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:975 E THIRD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-7806
Practice Address - Fax:423-778-2360
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN46237163W00000X
TNAPN08976367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000580566AMedicaid
TN3604262Medicaid
TN430030816OtherRAILROAD MEDICARE
NC8052354Medicaid
GAN366445OtherWELLCARE (GA MEDICAID)
AL009709980Medicaid
TN3049757OtherBLUE CROSS BLUE SHIELD TN
TN430030816OtherRAILROAD MEDICARE