Provider Demographics
NPI:1114370616
Name:PARKER, BLAINE A (PTA)
Entity Type:Individual
Prefix:MS
First Name:BLAINE
Middle Name:A
Last Name:PARKER
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 1:2200 GUM BRANCH RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4574
Mailing Address - Country:US
Mailing Address - Phone:910-353-9800
Mailing Address - Fax:
Practice Address - Street 1:2200 GUM BRANCH RD
Practice Address - Street 2:SUITE G
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-4574
Practice Address - Country:US
Practice Address - Phone:910-353-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5957225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant