Provider Demographics
NPI:1710075676
Name:EVANS, ANGELA JEAN (PT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:JEAN
Last Name:EVANS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:JEAN
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:WAHOO
Mailing Address - State:NE
Mailing Address - Zip Code:68066-0427
Mailing Address - Country:US
Mailing Address - Phone:402-443-4555
Mailing Address - Fax:402-443-4554
Practice Address - Street 1:559 W 15TH ST
Practice Address - Street 2:
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-1280
Practice Address - Country:US
Practice Address - Phone:402-786-0476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist