Provider Demographics
NPI:1194076299
Name:BLAIR, BRENT A (PTA)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:A
Last Name:BLAIR
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GREYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-9154
Mailing Address - Country:US
Mailing Address - Phone:304-860-1952
Mailing Address - Fax:
Practice Address - Street 1:200 GREYSTONE DR
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813-9154
Practice Address - Country:US
Practice Address - Phone:304-860-1952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA 001737225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant