Basic Information
| Provider Information | |||||||||
| NPI: | 1174502603 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 PROVIDENCE DR | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075610005 | ||||||||
| FaxNumber: | 9075639140 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 HOSPITAL PL | ||||||||
| Address2: | |||||||||
| City: | SOLDOTNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996696999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077144404 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 46976 | MN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 872956500 | 05 | MN | MEDICAID |