Basic Information
| Provider Information | |||||||||
| NPI: | 1437528148 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | JACOB | ||||||||
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| Credential: | BSN, RN, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24776 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374224776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772881799 | ||||||||
| FaxNumber: | 8559172023 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653809070 | ||||||||
| FaxNumber: | 8653809093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2015 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 180244 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.