Provider Demographics
NPI:1861852428
Name:HATAKEYAMA, BRENT YONEO (ATC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:YONEO
Last Name:HATAKEYAMA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 CALLAN AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4503
Mailing Address - Country:US
Mailing Address - Phone:408-427-2160
Mailing Address - Fax:
Practice Address - Street 1:184 CALLAN AVE APT 210
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4503
Practice Address - Country:US
Practice Address - Phone:408-427-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000115642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer