Provider Demographics
NPI:1770259210
Name:BERGQUIST, BLAIR (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 OLEANDER DR
Mailing Address - Street 2:STE 211
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4722
Mailing Address - Country:US
Mailing Address - Phone:910-398-6301
Mailing Address - Fax:
Practice Address - Street 1:5710 OLEANDER DR STE 211
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4722
Practice Address - Country:US
Practice Address - Phone:920-398-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16933225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist