Provider Demographics
NPI:1982870275
Name:EVANS, PAUL (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6263 POPLAR AVE
Mailing Address - Street 2:STE 801
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4701
Mailing Address - Country:US
Mailing Address - Phone:901-685-7227
Mailing Address - Fax:267-321-2079
Practice Address - Street 1:7900 AIRWAYS BLVD BLDG A
Practice Address - Street 2:STE 2
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4113
Practice Address - Country:US
Practice Address - Phone:662-536-4096
Practice Address - Fax:662-536-4099
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7622225100000X
MSPT3737225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS256594Medicare Oscar/Certification