Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 05011654A | IN |
N | 2251X0800X | Physical Therapist - Orthopedic | PT010453 | GA |
NPI | 1033493622 |
---|---|
Provider Name | Jonathan Evans |
First Address | Fort Wayne, IN 46845-2079 |
Second Address | Fort Wayne, IN 46845-8201 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/10/2011 |
Last Update Date | 25/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201289270 | (05) | IN |