Provider Demographics
NPI:1740048743
Name:JOHNSON, EVAN THOMAS
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:THOMAS
Last Name:JOHNSON
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 1:410 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-3049
Mailing Address - Country:US
Mailing Address - Phone:740-672-6627
Mailing Address - Fax:
Practice Address - Street 1:410 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-3049
Practice Address - Country:US
Practice Address - Phone:740-672-6627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTW428457347C00000X
OH374U00000X
376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No347C00000XTransportation ServicesPrivate VehicleGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemaker