Healthcare Provider Details

I. General information

NPI: 1699226506
Provider Name (Legal Business Name): MATTHEW BLAIR PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 N FOWLER AVE
SILVER CITY NM
88061-7210
US

IV. Provider business mailing address

PO BOX 427
NORA IL
61059-0427
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-3127
  • Fax:
Mailing address:
  • Phone: 608-228-1721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06006588A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2561-19
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number10061
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2349
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPT-2023-2389
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: