Provider Demographics
NPI:1215592845
Name:EVANGELISTA, JED EDISON MANCE (PT)
Entity Type:Individual
Prefix:MR
First Name:JED EDISON
Middle Name:MANCE
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8532 125TH ST
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3311
Mailing Address - Country:US
Mailing Address - Phone:410-629-9872
Mailing Address - Fax:
Practice Address - Street 1:8532 125TH ST
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3311
Practice Address - Country:US
Practice Address - Phone:410-629-9872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist