Provider Demographics
NPI:1437366861
Name:EVANS, CYD (PT)
Entity Type:Individual
Prefix:
First Name:CYD
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
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:PO BOX 90685
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-0685
Mailing Address - Country:US
Mailing Address - Phone:505-238-6282
Mailing Address - Fax:505-856-7226
Practice Address - Street 1:11520 CORONADO AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2431
Practice Address - Country:US
Practice Address - Phone:505-238-6282
Practice Address - Fax:505-856-7226
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1314171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65202309Medicaid