=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871246488
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACHARY CHRISTOPHER EVANS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2022
-----------------------------------------------------
Last Update Date | 02/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 626 SHIELDS AVE
-----------------------------------------------------
City | WABASHA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55981-1142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-565-4581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 2ND ST SE
-----------------------------------------------------
City | GLENWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56334-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-334-1314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A2736
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------