Basic Information
| Provider Information | |||||||||
| NPI: | 1235495011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RANDO | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3131 NEWMARK DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453425400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374388910 | ||||||||
| FaxNumber: | 9374364984 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 SOUTHERN BLVD. | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958166 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2012 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 35.122407 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0096394 | 05 | OH | MEDICAID |