Provider Demographics
NPI:1497966816
Name:EVANS, JOHN R (CMT, ABW, RYT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:EVANS
Suffix:
Gender:M
Credentials:CMT, ABW, RYT
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 307
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94942-0307
Mailing Address - Country:US
Mailing Address - Phone:415-717-7764
Mailing Address - Fax:
Practice Address - Street 1:643A EAST BLITHEDALE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94942
Practice Address - Country:US
Practice Address - Phone:415-717-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANOT APPLICABLE174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist