Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 070015322 | IL |
Y | 2251X0800X | Physical Therapist - Orthopedic | 070-015322 | IL |
NPI | 1053418087 |
---|---|
Provider Name | Jason Travis Hiatt |
First Address | Sycamore, IL 60178-3175 |
Second Address | Sycamore, IL 60178-3175 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 16/11/2017 |