Provider Demographics
NPI:1689814212
Name:HAZEN, MATTHEW TYLER (PTA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:TYLER
Last Name:HAZEN
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 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-2444
Mailing Address - Country:US
Mailing Address - Phone:712-542-5164
Mailing Address - Fax:
Practice Address - Street 1:600 MANOR DR
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2444
Practice Address - Country:US
Practice Address - Phone:712-542-5164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004029638225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant