Healthcare Provider Details

I. General information

NPI: 1740373117
Provider Name (Legal Business Name): ROGER J BLANDFORD PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 EDWARD CURD LN
FRANKLIN TN
37067-5791
US

IV. Provider business mailing address

317 SEVEN SPRINGS WAY STE 101
BRENTWOOD TN
37027-4576
US

V. Phone/Fax

Practice location:
  • Phone: 615-791-2630
  • Fax: 615-791-2639
Mailing address:
  • Phone: 615-370-9992
  • Fax: 615-370-9665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006042
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9105450
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3915
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1436
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: