Provider Demographics
NPI:1104050095
Name:BLITZ, BRIAN KEITH (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:BLITZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ROBERT PITT DR
Mailing Address - Street 2:
Mailing Address - City:MONSEY
Mailing Address - State:NY
Mailing Address - Zip Code:10952-3333
Mailing Address - Country:US
Mailing Address - Phone:201-753-8989
Mailing Address - Fax:
Practice Address - Street 1:40 ROBERT PITT DR
Practice Address - Street 2:
Practice Address - City:MONSEY
Practice Address - State:NY
Practice Address - Zip Code:10952-3333
Practice Address - Country:US
Practice Address - Phone:201-753-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00001400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant