Healthcare Provider Details

I. General information

NPI: 1679939581
Provider Name (Legal Business Name): EVAN ROBERT LAZ FLYNN P.T.,D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 03/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 MAIN ST STE D
WINOOSKI VT
05404-1380
US

IV. Provider business mailing address

321 MAIN ST STE D
WINOOSKI VT
05404-1380
US

V. Phone/Fax

Practice location:
  • Phone: 802-864-3785
  • Fax: 802-864-0274
Mailing address:
  • Phone: 802-864-3785
  • Fax: 802-864-0274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number293084
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4587
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040.0133981
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: