Provider Demographics
NPI:1710449210
Name:HANAN, RAYMOND SCOTT (PTA)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:SCOTT
Last Name:HANAN
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 1:2350 250TH ST SPC 45
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-3815
Mailing Address - Country:US
Mailing Address - Phone:310-626-3332
Mailing Address - Fax:
Practice Address - Street 1:6263 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-3823
Practice Address - Country:US
Practice Address - Phone:414-451-0543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49888225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant