Healthcare Provider Details

I. General information

NPI: 1093485369
Provider Name (Legal Business Name): GERARD-KYLE BLASA ABAD DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1163 JOHNSON FERRY RD STE 100
MARIETTA GA
30068-2764
US

IV. Provider business mailing address

1163 JOHNSON FERRY RD STE 100
MARIETTA GA
30068-2764
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-8066
  • Fax: 833-479-2087
Mailing address:
  • Phone: 404-355-8066
  • Fax: 833-479-2087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016142
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: