Healthcare Provider Details

I. General information

NPI: 1295986388
Provider Name (Legal Business Name): AMANDA SUSON BLAIR D.P.T,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1458 HENSLEY FARM RD
MARSHALL AR
72650-8672
US

IV. Provider business mailing address

1458 HENSLEY FARM RD
MARSHALL AR
72650-8672
US

V. Phone/Fax

Practice location:
  • Phone: 870-448-6232
  • Fax:
Mailing address:
  • Phone: 870-448-6232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberPT 3102
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: