Provider Demographics
NPI:1528855368
Name:BLAGG, MATTHEW SCOTT (STUDENT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SCOTT
Last Name:BLAGG
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 HEDGE APPLE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-2877
Mailing Address - Country:US
Mailing Address - Phone:270-703-2718
Mailing Address - Fax:
Practice Address - Street 1:1035 14TH AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-3050
Practice Address - Country:US
Practice Address - Phone:615-327-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program