MEDICARE: TONJA RENEE EVANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT003156	GA

General Provider Information

NPI Number	:	1093288599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONJA RENEE EVANS

Provider Business Mailing Address
First Line	:	PO BOX 370
Second Line	:
City	:	FORTSON
State	:	GA
Zip	:	31808-0370
Country	:	US
Telephone Number	:
Fax Number	:	706-494-3008

Provider Business Practice Location Address
First Line	:	99 HILL HAVEN RD
Second Line	:
City	:	GREENVILLE
State	:	GA
Zip	:	30222-3107
Country	:	US
Telephone Number	:	706-672-4241
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2019
Last Update Date	:	06/08/2020

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