Provider Demographics
NPI:1245050798
Name:MICHELSON, EVAN JAMES
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:JAMES
Last Name:MICHELSON
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 1:2085 ARROYO VISTA LN
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-8770
Mailing Address - Country:US
Mailing Address - Phone:928-530-8395
Mailing Address - Fax:
Practice Address - Street 1:2403 N STOCKTON HILL RD STE 4AND5
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4188
Practice Address - Country:US
Practice Address - Phone:928-529-5311
Practice Address - Fax:928-529-5313
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-010285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist