Provider Demographics
NPI:1821705278
Name:HAUN, NICHOLAS TILLY (PTA, CEAS II)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:TILLY
Last Name:HAUN
Suffix:
Gender:M
Credentials:PTA, CEAS II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 PILGRIM BLVD
Mailing Address - Street 2:
Mailing Address - City:HARTFORD CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47348-1382
Mailing Address - Country:US
Mailing Address - Phone:765-348-4197
Mailing Address - Fax:
Practice Address - Street 1:410 PILGRIM BOULEVARD
Practice Address - Street 2:
Practice Address - City:HARTFORD CITY
Practice Address - State:IN
Practice Address - Zip Code:47348-1382
Practice Address - Country:US
Practice Address - Phone:765-348-4197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005092A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7Medicaid