Provider Demographics
NPI:1346735073
Name:EVANS, RAYMOND (PTA)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:EVANS
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 1:401 CHANDLER RD
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-1243
Mailing Address - Country:US
Mailing Address - Phone:864-879-1370
Mailing Address - Fax:
Practice Address - Street 1:401 CHANDLER RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1243
Practice Address - Country:US
Practice Address - Phone:864-879-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3617225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC$$$$$$$$$Medicaid