Basic Information
| Provider Information | |||||||||
| NPI: | 1679581490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | BLAIR | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA/AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2564 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 HOSPITAL DRIVE | ||||||||
| Address2: | STE 410 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 06/04/2013 | ||||||||
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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 | 367H00000X | 002992 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970007565 | 01 | GA | RAILROAD MEDICARE | OTHER | 100001226B | 05 | GA | MEDICAID | 100001226D | 05 | GA | MEDICAID | 100001226C | 05 | GA | MEDICAID | 326185 | 01 | GA | WELLCARE | OTHER | 100001226A | 05 | GA | MEDICAID |