Provider Demographics
NPI:1679853816
Name:EVANS, PATRICIA MARY (OTA)
Entity Type:Individual
Prefix:MISS
First Name:PATRICIA
Middle Name:MARY
Last Name:EVANS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4328 ALBANY POST RD
Mailing Address - Street 2:APT 2
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538-3608
Mailing Address - Country:US
Mailing Address - Phone:518-779-4948
Mailing Address - Fax:
Practice Address - Street 1:4885 ROUTE 9
Practice Address - Street 2:
Practice Address - City:STAATSBURG
Practice Address - State:NY
Practice Address - Zip Code:12580-6028
Practice Address - Country:US
Practice Address - Phone:845-889-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007971172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker