MEDICARE: PETER J. HAZZARD P.T.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PT A-17349	FL
2	225200000X	Physical Therapy Assistant	PT A-0429	NV

General Provider Information

NPI Number	:	1194948950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER J. HAZZARD P.T.A.

Provider Business Mailing Address
First Line	:	1500 MEMOLI LN APT B3
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-6339
Country	:	US
Telephone Number	:	702-259-9601
Fax Number	:

Provider Business Practice Location Address
First Line	:	3955 SWENSON ST APT 381
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7261
Country	:	US
Telephone Number	:	702-369-4450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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