Provider Demographics
NPI:1487400602
Name:BLAIR, MICHAEL PR (FNP-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PR
Last Name:BLAIR
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5013
Mailing Address - Country:US
Mailing Address - Phone:208-880-1928
Mailing Address - Fax:
Practice Address - Street 1:216 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5013
Practice Address - Country:US
Practice Address - Phone:208-880-1928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-45980163WE0003X
ID1361873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163WE0003XNursing Service ProvidersRegistered NurseEmergency