Provider Demographics
NPI:1558658781
Name:HOGAN, IAN (LMT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:HOGAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SOLAR DR
Mailing Address - Street 2:C
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3402
Mailing Address - Country:US
Mailing Address - Phone:518-406-8788
Mailing Address - Fax:
Practice Address - Street 1:11 SOLAR DR
Practice Address - Street 2:C
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3402
Practice Address - Country:US
Practice Address - Phone:518-406-8788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024782225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist