Healthcare Provider Details

I. General information

NPI: 1275376568
Provider Name (Legal Business Name): HARRISON BLAKE HANSARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13341 HARPLEY CT
ALPHARETTA GA
30004-4926
US

IV. Provider business mailing address

13341 HARPLEY CT
ALPHARETTA GA
30004-4926
US

V. Phone/Fax

Practice location:
  • Phone: 678-507-6443
  • Fax:
Mailing address:
  • Phone: 678-507-6443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberGAA-CRNA004158
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-185336
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: