Basic Information
| Provider Information | |||||||||
| NPI: | 1518343003 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | EVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4210 E BASELINE RD | ||||||||
| Address2: | 106 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805032373 | ||||||||
| FaxNumber: | 4807825213 | ||||||||
| Practice Location | |||||||||
| Address1: | 4210 E BASELINE RD | ||||||||
| Address2: | 106 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805032373 | ||||||||
| FaxNumber: | 4807825213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2015 | ||||||||
| LastUpdateDate: | 08/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11733 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.