Provider Demographics
NPI:1144472705
Name:BLAIR, HEIDI J (PA)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:J
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2827
Mailing Address - Country:US
Mailing Address - Phone:804-526-0107
Mailing Address - Fax:804-526-4466
Practice Address - Street 1:211 TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2827
Practice Address - Country:US
Practice Address - Phone:804-526-0107
Practice Address - Fax:804-526-4466
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002040363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1144472705Medicaid
VA202000S82Medicare PIN