Provider Demographics
NPI:1295200145
Name:BLANCO, SARAH JANE TANILON
Entity Type:Individual
Prefix:
First Name:SARAH JANE
Middle Name:TANILON
Last Name:BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8523 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4322
Mailing Address - Country:US
Mailing Address - Phone:707-564-0430
Mailing Address - Fax:
Practice Address - Street 1:55 NORTHERN BLVD STE 103
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4058
Practice Address - Country:US
Practice Address - Phone:516-466-9300
Practice Address - Fax:516-466-9353
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant