Healthcare Provider Details

I. General information

NPI: 1861340887
Provider Name (Legal Business Name): ANDREA M BLAIR MS, LAT,ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA MCCOY MS, LAT,ATC

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 NEW FORSYTH RD
MACON GA
31210-5770
US

IV. Provider business mailing address

5131 IDLEWOOD DR
MACON GA
31210-2946
US

V. Phone/Fax

Practice location:
  • Phone: 478-238-5757
  • Fax:
Mailing address:
  • Phone: 678-227-9801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT004493
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: