Provider Demographics
NPI:1124324611
Name:BLIZNIAK, MICHEAL PATRICK (DPT)
Entity type:Individual
Prefix:
First Name:MICHEAL
Middle Name:PATRICK
Last Name:BLIZNIAK
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 1:8301 161ST AVE NE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3858
Mailing Address - Country:US
Mailing Address - Phone:425-284-1767
Mailing Address - Fax:425-284-3302
Practice Address - Street 1:8301 161ST AVE NE
Practice Address - Street 2:SUITE 103
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3858
Practice Address - Country:US
Practice Address - Phone:425-284-1767
Practice Address - Fax:425-284-3302
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60194846225100000X
OR60019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500652523Medicaid
ORR167737Medicare PIN