Provider Demographics
NPI:1235258948
Name:BLAZER, JO ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:ELIZABETH
Last Name:BLAZER
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 1:48 COLONY PARK DR
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550-3987
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 POINCIANA BLVD
Practice Address - Street 2:SUITE #4
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550-7049
Practice Address - Country:US
Practice Address - Phone:850-269-1717
Practice Address - Fax:850-269-2022
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 17401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4011Medicare ID - Type Unspecified