Provider Demographics
NPI:1558558445
Name:HERRERA, BLAS (PT)
Entity type:Individual
Prefix:
First Name:BLAS
Middle Name:
Last Name:HERRERA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:BLAS
Other - Middle Name:
Other - Last Name:HERRERA
Other - Suffix:VIII
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1515 EUBANK BLVD SE
Mailing Address - Street 2:MS 1019
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-3453
Mailing Address - Country:US
Mailing Address - Phone:505-844-3108
Mailing Address - Fax:
Practice Address - Street 1:1515 EUBANK BLVD SE
Practice Address - Street 2:MS 1019
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-3453
Practice Address - Country:US
Practice Address - Phone:505-844-3108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3864225100000X
AZ7322225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist