Provider Demographics
NPI:1932178589
Name:TANNER, BLAIR ANTHONY (PT)
Entity Type:Individual
Prefix:MR
First Name:BLAIR
Middle Name:ANTHONY
Last Name:TANNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 TATTENHALL DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-2406
Mailing Address - Country:US
Mailing Address - Phone:919-303-8399
Mailing Address - Fax:
Practice Address - Street 1:2709 BLUE RIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6462
Practice Address - Country:US
Practice Address - Phone:919-784-4696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10009225100000X
GAPT003109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079UUOtherBLUECROSS BLUESHIELD NC