Provider Demographics
NPI:1649444324
Name:SHORT, BLAIR P
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:P
Last Name:SHORT
Suffix:
Gender:F
Credentials:
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 23740
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37933-1740
Mailing Address - Country:US
Mailing Address - Phone:865-549-4342
Mailing Address - Fax:865-549-4341
Practice Address - Street 1:10810 PARKSIDE DR
Practice Address - Street 2:SUITE G11
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1979
Practice Address - Country:US
Practice Address - Phone:865-218-6660
Practice Address - Fax:865-218-6661
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000110899363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3704598Medicaid
TN3704598Medicare PIN