Provider Demographics
NPI:1396805495
Name:HANAN, BENJAMIN L (PTA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
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 1:700 WEST AVE S
Mailing Address - Street 2:ATTN PHYSICIAN SERVICES
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4783
Mailing Address - Country:US
Mailing Address - Phone:608-392-4156
Mailing Address - Fax:608-392-9898
Practice Address - Street 1:191 THEATRE RD
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8679
Practice Address - Country:US
Practice Address - Phone:608-392-5004
Practice Address - Fax:608-392-5791
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1359225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant