Provider Demographics
NPI:1326042854
Name:EVANS, DONALD RYAN (OT)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:RYAN
Last Name:EVANS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S BEST AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUTPORT
Mailing Address - State:PA
Mailing Address - Zip Code:18088-1217
Mailing Address - Country:US
Mailing Address - Phone:610-760-1520
Mailing Address - Fax:610-760-1721
Practice Address - Street 1:421 S BEST AVE
Practice Address - Street 2:
Practice Address - City:WALNUTPORT
Practice Address - State:PA
Practice Address - Zip Code:18088-1217
Practice Address - Country:US
Practice Address - Phone:610-760-1520
Practice Address - Fax:610-760-1721
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC005079L225X00000X
NJ46TR00311700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001676374Medicaid
PA001676374Medicaid