Provider Demographics
NPI:1437856895
Name:THOMPSON, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:THOMPSON
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 1:4254 E SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-9701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:238 EDGARTOWN-VINEYARD HAVEN RD
Practice Address - Street 2:
Practice Address - City:EDGARTOWN
Practice Address - State:MA
Practice Address - Zip Code:02539
Practice Address - Country:US
Practice Address - Phone:508-693-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant