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General NPI Number Information
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NPI Number | 1992231732
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Entity Type | Individual
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Provider Name | ETHAN BLANKESPOOR PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 03/05/2020
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Provider Practice Location Address
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Address Line | 3800 AMERICAN BLVD W # 200
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City | BLOOMINGTON
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State | MN
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Zip | 55431-4420
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Country | US
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Telephone | 952-831-8742
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Fax |
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Provider Business Mailing Address
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Address Line | 6605 NICOLLET AVE
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City | RICHFIELD
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State | MN
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Zip | 55423-2463
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Country | US
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Telephone | 612-872-2700
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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 | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 1974
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License Number State | SD
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 11163
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License Number State | MN
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