Provider Demographics
NPI:1306397831
Name:MOREHEAD, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:MOREHEAD
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 1:5160 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ND
Mailing Address - Zip Code:58504-9333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5160 LINCOLN ROAD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ND
Practice Address - Zip Code:58504
Practice Address - Country:US
Practice Address - Phone:651-331-1278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer