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General NPI Number Information
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NPI Number | 1245050798
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Entity Type | Individual
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Provider Name | EVAN JAMES MICHELSON
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Gender | Male
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Dates
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Enumeration Date | 10/10/2024
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Last Update Date | 10/10/2024
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Provider Practice Location Address
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Address Line | 2403 N STOCKTON HILL RD STE 4AND5
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City | KINGMAN
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State | AZ
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Zip | 86401-4188
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Country | US
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Telephone | 928-529-5311
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Fax | 928-529-5313
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Provider Business Mailing Address
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Address Line | 2085 ARROYO VISTA LN
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City | KINGMAN
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State | AZ
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Zip | 86401-8770
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Country | US
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Telephone | 928-530-8395
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | LPT-010285
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License Number State | AZ
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