Provider Demographics
NPI:1285418715
Name:BLANTON, CONNOR ALEXANDER
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:ALEXANDER
Last Name:BLANTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 W MOUNTAIN VIEW RD APT 2104
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2536
Mailing Address - Country:US
Mailing Address - Phone:704-473-6507
Mailing Address - Fax:
Practice Address - Street 1:1043 JACK VEST DRIVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614
Practice Address - Country:US
Practice Address - Phone:423-439-5264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ086335Medicaid