Provider Demographics
NPI:1265197255
Name:HATLEY, NICHOLAS PAUL (PTA)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:PAUL
Last Name:HATLEY
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 1:1234 W CAMERON AVE APT 136
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3554
Mailing Address - Country:US
Mailing Address - Phone:626-466-6470
Mailing Address - Fax:
Practice Address - Street 1:1234 W CAMERON AVE APT 136
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3554
Practice Address - Country:US
Practice Address - Phone:626-466-6470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51491225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant