Provider Demographics
NPI:1104299064
Name:BLANTON, JOSHUA ALEXANDER
Entity type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:ALEXANDER
Last Name:BLANTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13049 N 500 E
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:IN
Mailing Address - Zip Code:47342-9603
Mailing Address - Country:US
Mailing Address - Phone:765-810-5731
Mailing Address - Fax:
Practice Address - Street 1:2000 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47306-1022
Practice Address - Country:US
Practice Address - Phone:765-289-1241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-01
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer