Provider Demographics
NPI:1649393844
Name:HANAMAN, DEREK (MPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:HANAMAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 STILL WATER CT
Mailing Address - Street 2:
Mailing Address - City:DOUSMAN
Mailing Address - State:WI
Mailing Address - Zip Code:53118-8832
Mailing Address - Country:US
Mailing Address - Phone:414-406-1664
Mailing Address - Fax:
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6317-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist