Provider Demographics
NPI:1144311770
Name:REGAN, DAVID WAYNE (PT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WAYNE
Last Name:REGAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-1521
Mailing Address - Country:US
Mailing Address - Phone:337-477-8823
Mailing Address - Fax:337-477-0143
Practice Address - Street 1:611 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-1521
Practice Address - Country:US
Practice Address - Phone:337-477-8823
Practice Address - Fax:337-477-0143
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5 T 853Medicare ID - Type Unspecified