Provider Demographics
NPI:1295986388
Name:BLAIR, AMANDA SUSON (DPT,)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUSON
Last Name:BLAIR
Suffix:
Gender:F
Credentials:DPT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1458 HENSLEY FARM RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:AR
Mailing Address - Zip Code:72650-8672
Mailing Address - Country:US
Mailing Address - Phone:870-448-6232
Mailing Address - Fax:
Practice Address - Street 1:1458 HENSLEY FARM RD
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:AR
Practice Address - Zip Code:72650-8672
Practice Address - Country:US
Practice Address - Phone:870-448-6232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 3102171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider