Healthcare Provider Details

I. General information

NPI: 1225488281
Provider Name (Legal Business Name): LA'TORIA EVANS LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1434 CENTRAL AVE E
WIGGINS MS
39577-9602
US

IV. Provider business mailing address

1436 CENTRAL AVE E
WIGGINS MS
39577-9602
US

V. Phone/Fax

Practice location:
  • Phone: 601-928-1889
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 4590
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: