Provider Demographics
NPI:1144433954
Name:BLAIR, CHARLES EBENEZER (PHD, RN, CS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EBENEZER
Last Name:BLAIR
Suffix:
Gender:M
Credentials:PHD, RN, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
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Mailing Address - Street 1:1120 NASA PKWY 220W
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-3362
Mailing Address - Country:US
Mailing Address - Phone:903-312-7268
Mailing Address - Fax:281-331-4197
Practice Address - Street 1:1120 NASA PKWY 220W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-3362
Practice Address - Country:US
Practice Address - Phone:903-312-7268
Practice Address - Fax:281-331-4197
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX539564364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0443392Medicaid
TXNP7054OtherBLUECROSS & BLUESHIELD PR
TXR17107Medicare UPIN
TX0443392Medicaid