Provider Demographics
NPI:1023365947
Name:QUEEN, EVAN (PTA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:QUEEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 RILEY ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4717
Mailing Address - Country:US
Mailing Address - Phone:803-236-1707
Mailing Address - Fax:
Practice Address - Street 1:2825 CARTER RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1712
Practice Address - Country:US
Practice Address - Phone:803-469-4032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC837225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant