Provider Demographics
NPI:1760110837
Name:SILLAN, PETER G (PTA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:SILLAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:PIERRE
Other - Middle Name:G
Other - Last Name:SILLAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:802 SHADOW GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7236
Mailing Address - Country:US
Mailing Address - Phone:214-945-6701
Mailing Address - Fax:
Practice Address - Street 1:3645 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3242
Practice Address - Country:US
Practice Address - Phone:214-945-6701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2109536225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant