Healthcare Provider Details

I. General information

NPI: 1619613874
Provider Name (Legal Business Name): EVAN CLAY SMITH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14800 W MOUNTAIN VIEW BLVD STE 260
SURPRISE AZ
85374-4797
US

IV. Provider business mailing address

14800 W MOUNTAIN VIEW BLVD STE 260
SURPRISE AZ
85374-4797
US

V. Phone/Fax

Practice location:
  • Phone: 623-556-5013
  • Fax: 623-556-9290
Mailing address:
  • Phone: 623-556-5013
  • Fax: 623-556-9290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT32336
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberLPT32336
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License NumberLPT32336
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberLPT32336
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: