Basic Information
| Provider Information | |||||||||
| NPI: | 1417064718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1985 JEFFERSON DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224016233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403736647 | ||||||||
| FaxNumber: | 5409519112 | ||||||||
| Practice Location | |||||||||
| Address1: | 2617 SHEFFIELD DRIVE | ||||||||
| Address2: | |||||||||
| City: | BLACKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409532210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110002641 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00455781 | 01 | VA | MEDICARE RAILROAD | OTHER | 1072845 | 01 | PA CERTIFICATION | OTHER | 1417064718 | 05 | VA | MEDICAID |