Provider Demographics
NPI:1639116254
Name:BLAIR, MARK M (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:BLAIR
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 627
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36831-0627
Mailing Address - Country:US
Mailing Address - Phone:800-232-5703
Mailing Address - Fax:
Practice Address - Street 1:2000 PEPPERELL PKWY
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5452
Practice Address - Country:US
Practice Address - Phone:334-528-2499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN209001203367500000X
IL041217895163W00000X
AL1-094483367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL039441OtherCRNA RECERTIFICATION
IL209001203OtherCRNA LIC
AL1-094483OtherRN & CRNA LICENSE
AL1-094483OtherRN & CRNA LICENSE