Provider Demographics
NPI:1104553262
Name:BLANCO, MICHAEL RYAN (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:BLANCO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 AUSTIN PL
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604-1438
Mailing Address - Country:US
Mailing Address - Phone:201-220-9049
Mailing Address - Fax:
Practice Address - Street 1:31 VER VALEN ST
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-2699
Practice Address - Country:US
Practice Address - Phone:201-784-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02105400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA02105400OtherNEW JERSEY DIVISION OF CONSUMER AFFAIRS