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General NPI Number Information
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NPI Number | 1760110837
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Entity Type | Individual
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Provider Name | PETER G SILLAN PTA
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Gender | Male
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Dates
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Enumeration Date | 08/08/2022
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Last Update Date | 08/08/2022
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Provider Practice Location Address
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Address Line | 3645 N BEACH ST
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City | FORT WORTH
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State | TX
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Zip | 76137-3242
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Country | US
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Telephone | 214-945-6701
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Fax |
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Provider Business Mailing Address
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Address Line | 802 SHADOW GLEN DR
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City | SOUTHLAKE
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State | TX
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Zip | 76092-7236
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Country | US
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Telephone | 214-945-6701
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2109536
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License Number State | TX
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