Basic Information
| Provider Information | |||||||||
| NPI: | 1639116254 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 627 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368310627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002325703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 PEPPERELL PKWY | ||||||||
| Address2: | |||||||||
| City: | OPELIKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368015452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345282499 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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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 | 209001203 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 041217895 | IL | N | Nursing Service Providers | Registered Nurse | 367500000X | 1-094483 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 039441 | 01 | AL | CRNA RECERTIFICATION | OTHER | 209001203 | 01 | IL | CRNA LIC | OTHER | 1-094483 | 01 | AL | RN & CRNA LICENSE | OTHER |