Basic Information
| Provider Information | |||||||||
| NPI: | 1740373117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANDFORD | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 SEVEN SPRINGS WAY STE 101 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153709992 | ||||||||
| FaxNumber: | 6153709665 | ||||||||
| Practice Location | |||||||||
| Address1: | 317 SEVEN SPRINGS WAY STE 101 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153709992 | ||||||||
| FaxNumber: | 6153709665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2006 | ||||||||
| LastUpdateDate: | 05/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AL1436 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | 006042 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA 9105450 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3915 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003108303B | 05 | GA | MEDICAID | Q051014 | 05 | TN | MEDICAID | 003108303C | 05 | GA | MEDICAID |