Provider Demographics
NPI:1740373117
Name:BLANDFORD, ROGER J (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:J
Last Name:BLANDFORD
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 SEVEN SPRINGS WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4576
Mailing Address - Country:US
Mailing Address - Phone:615-370-9992
Mailing Address - Fax:615-370-9665
Practice Address - Street 1:3000 EDWARD CURD LN
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-5791
Practice Address - Country:US
Practice Address - Phone:615-791-2630
Practice Address - Fax:615-791-2639
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006042363A00000X
FLPA 9105450363A00000X
TN3915363A00000X
FLAL14362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ051014Medicaid
GA003108303CMedicaid
GA003108303BMedicaid