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General NPI Number Information
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NPI Number | 1225737869
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Entity Type | Individual
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Provider Name | THOMAS GERALD BLAKESLEE ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 03/02/2023
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Last Update Date | 03/02/2023
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Provider Practice Location Address
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Address Line | 1800 CAMPUS CENTER DR HPER WEST
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City | SALT LAKE CITY
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State | UT
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Zip | 84112
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Country | US
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Telephone | 302-220-1247
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Fax |
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Provider Business Mailing Address
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Address Line | 325 S ORCHARD DR APT D309
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City | NORTH SALT LAKE
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State | UT
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Zip | 84054-1873
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Country | US
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Telephone | 302-220-1247
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 12937807-4810
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License Number State | UT
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