Provider Demographics
NPI:1376516617
Name:BLASE, WALTER R (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:R
Last Name:BLASE
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 BASSETT CT SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-5528
Mailing Address - Country:US
Mailing Address - Phone:678-842-0212
Mailing Address - Fax:
Practice Address - Street 1:101 MARIETTA ST NW
Practice Address - Street 2:SUITE 1900
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-2720
Practice Address - Country:US
Practice Address - Phone:404-878-3513
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT000742174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist