MEDICARE: JEREMY BLAKE EVANS LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2065866	TX

General Provider Information

NPI Number	:	1326204603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY BLAKE EVANS LPTA

Provider Business Mailing Address
First Line	:	1618 KIRBY RD
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75006-7453
Country	:	US
Telephone Number	:	972-245-1573
Fax Number	:

Provider Business Practice Location Address
First Line	:	1618 KIRBY RD
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75006-7453
Country	:	US
Telephone Number	:	972-245-1573
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2008
Last Update Date	:	08/05/2008

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