Provider Demographics
NPI:1770120198
Name:HANES, TAYLOR RYAN (LAT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RYAN
Last Name:HANES
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:RYAN
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT
Mailing Address - Street 1:3000 WYLIE EAST DR
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-5701
Mailing Address - Country:US
Mailing Address - Phone:972-429-3150
Mailing Address - Fax:
Practice Address - Street 1:3000 WYLIE EAST DR
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-5701
Practice Address - Country:US
Practice Address - Phone:972-429-3150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT47072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty