Healthcare Provider Details

I. General information

NPI: 1265843494
Provider Name (Legal Business Name): BRIAN AUSTIN BLAIR PT, DPT, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2014
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N LINCOLN ST STE H
DIXON CA
95620-3260
US

IV. Provider business mailing address

125 N LINCOLN ST STE H
DIXON CA
95620-3260
US

V. Phone/Fax

Practice location:
  • Phone: 707-718-0151
  • Fax: 707-637-8152
Mailing address:
  • Phone: 707-718-0151
  • Fax: 707-637-8152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number41277
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: