Basic Information
| Provider Information | |||||||||
| NPI: | 1992231732 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANKESPOOR | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6605 NICOLLET AVE | ||||||||
| Address2: | |||||||||
| City: | RICHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554232463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128722700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3800 AMERICAN BLVD W # 200 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554314420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528318742 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 1974 | SD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 11163 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.