Provider Demographics
NPI:1154402022
Name:BLANKESPOOR, MARK A (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BLANKESPOOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 N PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1383
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 SE 9TH ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-2296
Practice Address - Country:US
Practice Address - Phone:641-621-0230
Practice Address - Fax:641-621-0319
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06121OtherWELLMARK
IA0423822Medicaid
IA06121OtherWELLMARK