MEDICARE: BLAINE ANTHONY BIRTZER DAT, LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1003278813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAINE ANTHONY BIRTZER DAT, LAT, ATC

Provider Business Mailing Address
First Line	:	1536 HEWITT AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-1205
Country	:	US
Telephone Number	:	715-214-3898
Fax Number	:

Provider Business Practice Location Address
First Line	:	1536 HEWITT AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-1284
Country	:	US
Telephone Number	:	651-523-3094
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	08/12/2025

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