1134477524 NPI number — BLAKE ANTHONY LANDRY PA-C

Table of content: BLAKE ANTHONY LANDRY PA-C (NPI 1134477524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134477524 NPI number — BLAKE ANTHONY LANDRY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDRY
Provider First Name:
BLAKE
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134477524
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 BILL CARRUTH PKWY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIRAM
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30141-3756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-422-1372
Provider Business Mailing Address Fax Number:
678-363-5170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 BILL CARRUTH PKWY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIRAM
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30141-3756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-422-1372
Provider Business Practice Location Address Fax Number:
678-363-5170
Provider Enumeration Date:
08/16/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  TA1743 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)