Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 05014201A | IN |
NPI | 1154990893 |
---|---|
Provider Name | Evan Jurjevic |
First Address | Fort Wayne, IN 46845-1701 |
Second Address | Fort Wayne, IN 46805-1018 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2021 |
Last Update Date | 30/06/2021 |