Healthcare Provider Details

I. General information

NPI: 1184897332
Provider Name (Legal Business Name): KELLY S BLAIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 SOUTH CEDAR ST #300/#200
TACOMA WA
98405
US

IV. Provider business mailing address

PO BOX 5299 MS: 737-3-PCON
TACOMA WA
98415-0299
US

V. Phone/Fax

Practice location:
  • Phone: 253-301-5280
  • Fax: 253-627-4608
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD60537891
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: