Provider Demographics
NPI:1124431457
Name:BLAIR, MATTHEW THOMAS (CRNA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BLAIR
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 KILLARNEY BEACH RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-1185
Mailing Address - Country:US
Mailing Address - Phone:423-503-8874
Mailing Address - Fax:
Practice Address - Street 1:1900 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6880
Practice Address - Country:US
Practice Address - Phone:989-894-3000
Practice Address - Fax:989-894-6138
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9306516367500000X
MI4704277505367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101868OtherAANA