Provider Demographics
NPI:1033452248
Name:EVERETT, TONY RAY
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:RAY
Last Name:EVERETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6408 MIRAGRANDE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-5533
Mailing Address - Country:US
Mailing Address - Phone:702-237-1633
Mailing Address - Fax:
Practice Address - Street 1:6408 MIRAGRANDE DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-5533
Practice Address - Country:US
Practice Address - Phone:702-237-1633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner