Healthcare Provider Details

I. General information

NPI: 1144183781
Provider Name (Legal Business Name): DYLAN HANNA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S RANGE LINE RD
JOPLIN MO
64804-3234
US

IV. Provider business mailing address

225 S HARRISON ST
JASPER MO
64755-8299
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-8760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2020033420
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: