Provider Demographics
NPI:1184719502
Name:BLAIR, PATRICIA (FPNP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:FPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 WYATTE TYRO RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635
Mailing Address - Country:US
Mailing Address - Phone:662-562-5481
Mailing Address - Fax:
Practice Address - Street 1:100 PRESTON MCKAY DR
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2350
Practice Address - Country:US
Practice Address - Phone:662-562-4428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR138480363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSQ06251Medicare UPIN
MS500001418Medicare ID - Type Unspecified
MS50001517Medicare ID - Type Unspecified