Basic Information
Provider Information | |||||||||
NPI: | 1205172665 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EVANS | ||||||||
FirstName: | KELCI | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6912 FM 1488 RD | ||||||||
Address2: | STE A | ||||||||
City: | MAGNOLIA | ||||||||
State: | TX | ||||||||
PostalCode: | 773541527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2813561945 | ||||||||
FaxNumber: | 2813561978 | ||||||||
Practice Location | |||||||||
Address1: | 6912 FM 1488 RD | ||||||||
Address2: | STE A | ||||||||
City: | MAGNOLIA | ||||||||
State: | TX | ||||||||
PostalCode: | 773541527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2813561945 | ||||||||
FaxNumber: | 2813561978 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2012 | ||||||||
LastUpdateDate: | 02/24/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1107267 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 263275773 | 01 | TX | TAX ID | OTHER |