Provider Demographics
NPI:1316453897
Name:HOGAN, SAMUEL JAMES (PTA)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:JAMES
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 1:4654 ONONDAGA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-3302
Mailing Address - Country:US
Mailing Address - Phone:315-475-7121
Mailing Address - Fax:
Practice Address - Street 1:4654 ONONDAGA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3302
Practice Address - Country:US
Practice Address - Phone:315-475-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010494-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant