Healthcare Provider Details

I. General information

NPI: 1619018165
Provider Name (Legal Business Name): EVELYN JANE LAZOR PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 HICKORY CIR
CORTLAND OH
44410-1170
US

IV. Provider business mailing address

108 HICKORY CIR
CORTLAND OH
44410-1170
US

V. Phone/Fax

Practice location:
  • Phone: 330-638-2658
  • Fax: 330-638-2663
Mailing address:
  • Phone: 330-638-2658
  • Fax: 330-638-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number237
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: