Provider Demographics
NPI:1043616287
Name:HYATT, NICHOLAS RYAN (PTA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
Last Name:HYATT
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 1:600 W NORTH BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5063
Mailing Address - Country:US
Mailing Address - Phone:352-728-6636
Mailing Address - Fax:352-787-4522
Practice Address - Street 1:600 W NORTH BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5063
Practice Address - Country:US
Practice Address - Phone:352-728-6636
Practice Address - Fax:352-787-4522
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA24859225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant