Healthcare Provider Details

I. General information

NPI: 1992231732
Provider Name (Legal Business Name): ETHAN BLANKESPOOR PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 AMERICAN BLVD W # 200
BLOOMINGTON MN
55431-4420
US

IV. Provider business mailing address

6605 NICOLLET AVE
RICHFIELD MN
55423-2463
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax:
Mailing address:
  • Phone: 612-872-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1974
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11163
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: