Provider Demographics
NPI:1083390884
Name:WILLIAMS, EVAN MATTHEW
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MATTHEW
Last Name:WILLIAMS
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 1:200 W. DOUGLAS AVE, STE 250
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:
Practice Address - Street 1:8550 MARSHALL DR, STE 210
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66214
Practice Address - Country:US
Practice Address - Phone:913-492-0333
Practice Address - Fax:913-492-0334
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-05968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist