Provider Demographics
NPI:1003278813
Name:BIRTZER, BLAINE ANTHONY (DAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:ANTHONY
Last Name:BIRTZER
Suffix:
Gender:M
Credentials:DAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 TERRACE DR APT 208
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1774
Mailing Address - Country:US
Mailing Address - Phone:715-214-3898
Mailing Address - Fax:
Practice Address - Street 1:1536 HEWITT AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1284
Practice Address - Country:US
Practice Address - Phone:651-523-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer