Provider Demographics
NPI:1679581482
Name:EVANS, THOMAS DALE
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DALE
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 1:813 CHARMING CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-2888
Mailing Address - Country:US
Mailing Address - Phone:615-874-9888
Mailing Address - Fax:615-883-6899
Practice Address - Street 1:244 JACKSON MEADOWS DR
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-1425
Practice Address - Country:US
Practice Address - Phone:615-874-9888
Practice Address - Fax:615-883-6899
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000010866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP00039795OtherRAILROAD MEDICARE
AL51512447OtherBLUECROSSBLUESHIELD OF AL
AL000092766Medicaid