Healthcare Provider Details

I. General information

NPI: 1144056938
Provider Name (Legal Business Name): EVAN W HURT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MAIN ST
CASSVILLE MO
65625-1154
US

IV. Provider business mailing address

PO BOX 815
CASSVILLE MO
65625-0815
US

V. Phone/Fax

Practice location:
  • Phone: 417-847-2221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2017024970
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: