Healthcare Provider Details

I. General information

NPI: 1124324611
Provider Name (Legal Business Name): MICHEAL PATRICK BLIZNIAK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8301 161ST AVE NE SUITE 103
REDMOND WA
98052-3858
US

IV. Provider business mailing address

8301 161ST AVE NE SUITE 103
REDMOND WA
98052-3858
US

V. Phone/Fax

Practice location:
  • Phone: 425-284-1767
  • Fax: 425-284-3302
Mailing address:
  • Phone: 425-284-1767
  • Fax: 425-284-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60194846
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60019
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: