Provider Demographics
NPI:1134218308
Name:EVANS, JEREMY WAYNE (PTA MT)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:WAYNE
Last Name:EVANS
Suffix:
Gender:M
Credentials:PTA MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 RUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311
Mailing Address - Country:US
Mailing Address - Phone:937-592-1625
Mailing Address - Fax:937-592-3489
Practice Address - Street 1:711 RUSH AVE
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311
Practice Address - Country:US
Practice Address - Phone:937-592-1625
Practice Address - Fax:937-592-3489
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA06368225200000X
OH33011899225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist