Provider Demographics
NPI:1366452237
Name:BLANCAS, MOSES ISAAC (LPT)
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:ISAAC
Last Name:BLANCAS
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-0520
Mailing Address - Country:US
Mailing Address - Phone:915-842-0504
Mailing Address - Fax:915-842-0448
Practice Address - Street 1:1721 N LEE TREVINO DR STE B
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4564
Practice Address - Country:US
Practice Address - Phone:915-590-1910
Practice Address - Fax:915-225-6422
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1147100225100000X, 2251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2802654-01Medicaid
TX8D3234Medicare ID - Type Unspecified