Provider Demographics
NPI:1902916216
Name:BLAS, LISA (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BLAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450077 STATE ROAD 200
Mailing Address - Street 2:
Mailing Address - City:CALLAHAN
Mailing Address - State:FL
Mailing Address - Zip Code:32011-3863
Mailing Address - Country:US
Mailing Address - Phone:904-980-0119
Mailing Address - Fax:904-879-9541
Practice Address - Street 1:450077 STATE ROAD 200
Practice Address - Street 2:
Practice Address - City:CALLAHAN
Practice Address - State:FL
Practice Address - Zip Code:32011-3863
Practice Address - Country:US
Practice Address - Phone:904-980-0119
Practice Address - Fax:904-879-9541
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000625539003OtherBLUE CROSS
NY9390538OtherIHA
00025703502OtherUNIVERA
000625539003OtherBLUE CROSS
NY9390538OtherIHA