Provider Demographics
NPI:1689962326
Name:EVANS-DERR, TERA NICOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:NICOLE
Last Name:EVANS-DERR
Suffix:
Gender:F
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 1:8880 NE 82ND TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64158-1313
Mailing Address - Country:US
Mailing Address - Phone:816-437-8262
Mailing Address - Fax:
Practice Address - Street 1:8880 NE 82ND TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64158-1313
Practice Address - Country:US
Practice Address - Phone:816-271-6636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012013469225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4170075Medicare PIN