Provider Demographics
NPI:1679939581
Name:FLYNN, EVAN ROBERT LAZ (PT,DPT)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:ROBERT LAZ
Last Name:FLYNN
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-1380
Mailing Address - Country:US
Mailing Address - Phone:802-864-3785
Mailing Address - Fax:802-864-0274
Practice Address - Street 1:321 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-1380
Practice Address - Country:US
Practice Address - Phone:802-864-3785
Practice Address - Fax:802-864-0274
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2018-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293084225100000X
ME4587225100000X
VT040.0133981225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist