Provider Demographics
NPI:1578019063
Name:EVERT, ETHAN R (PT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:R
Last Name:EVERT
Suffix:
Gender:M
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 67250
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-7250
Mailing Address - Country:US
Mailing Address - Phone:402-328-8833
Mailing Address - Fax:888-965-0959
Practice Address - Street 1:6540 S 84TH ST
Practice Address - Street 2:STE 100
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3909
Practice Address - Country:US
Practice Address - Phone:402-770-9775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2775225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist