MEDICARE: MISS ASHLEY NICOLE EVANS P.T.A.

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	225200000X	Physical Therapy Assistant	1543	OK

General Provider Information

NPI Number	:	1154567246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ASHLEY NICOLE EVANS P.T.A.

Provider Business Mailing Address
First Line	:	2239 N ELM ST
Second Line	:
City	:	MIAMI
State	:	OK
Zip	:	74354-1402
Country	:	US
Telephone Number	:	918-542-5186
Fax Number	:

Provider Business Practice Location Address
First Line	:	2239 N ELM ST
Second Line	:
City	:	MIAMI
State	:	OK
Zip	:	74354-1402
Country	:	US
Telephone Number	:	918-542-5186
Fax Number	:

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

Provider Enumeration Date	:	12/19/2008
Last Update Date	:	12/19/2008

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