Basic Information
| Provider Information | |||||||||
| NPI: | 1508370453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | NUTTA-ON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT, PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PROMJUNYAKUL | ||||||||
| OtherFirstName: | NUTTA-ON | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PT, PHD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 315 ROLLING MIST CT | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300224405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143241176 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6475 JIMMY CARTER BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300711734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702427744 | ||||||||
| FaxNumber: | 7703680164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2017 | ||||||||
| LastUpdateDate: | 11/29/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251N0400X | PTL.0014385 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology | 2251P0200X | PT013222 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 2251P0200X | PTL.0014385 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 2251N0400X | PT013222 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
No ID Information.