Provider Demographics
NPI:1356503684
Name:EVANS, PATRICIA ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
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:W312S8732 CHEROKEE PASS
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8832
Mailing Address - Country:US
Mailing Address - Phone:262-363-7858
Mailing Address - Fax:
Practice Address - Street 1:W312S8732 CHEROKEE PASS
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-8832
Practice Address - Country:US
Practice Address - Phone:262-363-7858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI233-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962677658Medicaid