Provider Demographics
NPI:1447229786
Name:EVERSON, DAVID ALLEN (RPT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALLEN
Last Name:EVERSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21395 JOHN MILLESS DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-4406
Mailing Address - Country:US
Mailing Address - Phone:763-428-2589
Mailing Address - Fax:763-428-4672
Practice Address - Street 1:21395 JOHN MILLESS DR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4402
Practice Address - Country:US
Practice Address - Phone:763-428-2589
Practice Address - Fax:763-428-4672
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist