MEDICARE: MRS. DIANE G BLAISING AU.D., FAAA, CCC-A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237600000X	Audiologist-Hearing Aid Fitter	51489	TX

General Provider Information

NPI Number	:	1568465128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANE G BLAISING AU.D., FAAA, CCC-A

Provider Business Mailing Address
First Line	:	7801 OAKMONT BLVD
Second Line	:	SUITE 109
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4204
Country	:	US
Telephone Number	:	817-263-1800
Fax Number	:	817-263-1802

Provider Business Practice Location Address
First Line	:	7801 OAKMONT BLVD
Second Line	:	SUITE 109
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4204
Country	:	US
Telephone Number	:	817-263-1800
Fax Number	:	817-263-1802

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	11/22/2016

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