Provider Demographics
NPI:1194956060
Name:HOGAN, PETER DANIEL (PTA)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:DANIEL
Last Name:HOGAN
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 1:8 RICHARDSON ST APT 5
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-3341
Mailing Address - Country:US
Mailing Address - Phone:617-965-2411
Mailing Address - Fax:
Practice Address - Street 1:200 GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1644
Practice Address - Country:US
Practice Address - Phone:781-391-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8261225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant