Healthcare Provider Details

I. General information

NPI: 1700327731
Provider Name (Legal Business Name): MIKE EVENSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 WASHINGTON BLVD
NEWCASTLE WY
82701-2972
US

IV. Provider business mailing address

1124 WASHINGTON BLVD
NEWCASTLE WY
82701-2972
US

V. Phone/Fax

Practice location:
  • Phone: 307-746-3720
  • Fax: 307-746-3723
Mailing address:
  • Phone: 307-746-3720
  • Fax: 307-746-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1421
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: