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General NPI Number Information
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NPI Number | 1669016887
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Entity Type | Individual
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Provider Name | BLAIZE MCMONAGLE PTA
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Gender | Male
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Dates
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Enumeration Date | 10/30/2019
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Last Update Date | 10/30/2019
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Provider Practice Location Address
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Address Line | 5121 MICHIGAN AVE
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City | SANFORD
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State | FL
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Zip | 32771-8574
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Country | US
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Telephone | 407-346-4997
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Fax |
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Provider Business Mailing Address
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Address Line | 755 MONROE RD UNIT 470738
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City | LAKE MONROE
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State | FL
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Zip | 32747-7525
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Country | US
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Telephone |
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA24352
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License Number State | FL
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