Provider Demographics
NPI:1528585999
Name:EVANS, ALBERT J
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:J
Last Name:EVANS
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 1:7504 PARKWAY DR UNIT 207
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1766
Mailing Address - Country:US
Mailing Address - Phone:843-743-9709
Mailing Address - Fax:
Practice Address - Street 1:5500 CAMPANILE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92182-0001
Practice Address - Country:US
Practice Address - Phone:619-594-4094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-27
Last Update Date:2017-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer