Healthcare Provider Details

I. General information

NPI: 1154774388
Provider Name (Legal Business Name): JESSE HOGAN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2016
Last Update Date: 07/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8109 RITCHIE HWY SUITE 601A
PASADENA MD
21122-6917
US

IV. Provider business mailing address

8109 RITCHIE HWY SUITE 601A
PASADENA MD
21122-6917
US

V. Phone/Fax

Practice location:
  • Phone: 410-533-3515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA4496
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: