Provider Demographics
NPI:1073025870
Name:BLASCHAK, KRISTINA (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:BLASCHAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 GOFFS FALLS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-6109
Mailing Address - Country:US
Mailing Address - Phone:800-995-2673
Mailing Address - Fax:
Practice Address - Street 1:3000 GOFFS FALLS RD STE 101
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-6109
Practice Address - Country:US
Practice Address - Phone:800-995-2673
Practice Address - Fax:800-995-2673
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2604-19225200000X
PATE010728225200000X
IN06005504A225200000X
OHPTA009166225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant