Provider Demographics
NPI:1598279986
Name:BLUE, REGINA EAST (PTA)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:EAST
Last Name:BLUE
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 1:8131 TWIN HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27306-9507
Mailing Address - Country:US
Mailing Address - Phone:910-571-1517
Mailing Address - Fax:
Practice Address - Street 1:8131 TWIN HARBOR DR
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:NC
Practice Address - Zip Code:27306-9507
Practice Address - Country:US
Practice Address - Phone:910-571-1517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
NCA670225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant