Provider Demographics
NPI:1194948950
Name:HAZZARD, PETER J (PTA)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:HAZZARD
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 1:1500 MEMOLI LN APT B3
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-6339
Mailing Address - Country:US
Mailing Address - Phone:702-259-9601
Mailing Address - Fax:
Practice Address - Street 1:3955 SWENSON ST APT 381
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7261
Practice Address - Country:US
Practice Address - Phone:702-369-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT A-17349225200000X
NVPT A-0429225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant