Basic Information
| Provider Information | |||||||||
| NPI: | 1770128746 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | EVANGELISTA | ||||||||
| FirstName: | JONALD | ||||||||
| MiddleName: | BOYLES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 N TENAYA WAY STE 180 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891281110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022402952 | ||||||||
| FaxNumber: | 7022430482 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 N TENAYA WAY STE 180 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891281110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022402952 | ||||||||
| FaxNumber: | 7022430482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2019 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 032653 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 4240 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.