Provider Demographics
NPI:1427542059
Name:DORN, BLAIR (PA-C)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:DORN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 E MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5556
Mailing Address - Country:US
Mailing Address - Phone:026-944-2900
Mailing Address - Fax:
Practice Address - Street 1:1635 E MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5556
Practice Address - Country:US
Practice Address - Phone:026-944-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA60917969363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2120853Medicaid