Provider Demographics
NPI:1700180072
Name:BLAIR, ROGER BYRON (PA-C)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:BYRON
Last Name:BLAIR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3009
Mailing Address - Country:US
Mailing Address - Phone:706-278-5961
Mailing Address - Fax:706-529-9588
Practice Address - Street 1:6120 ALABAMA HWY
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-2804
Practice Address - Country:US
Practice Address - Phone:706-935-6442
Practice Address - Fax:706-935-6441
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6111363AM0700X, 363AM0700X
TN001874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003119262BMedicaid