Basic Information
| Provider Information | |||||||||
| NPI: | 1609901024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 248 | ||||||||
| Address2: | 1343 A MONMOUTH ST | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973510248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038383001 | ||||||||
| FaxNumber: | 5038380994 | ||||||||
| Practice Location | |||||||||
| Address1: | 1343 A MONMOUTH ST | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973510248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038383001 | ||||||||
| FaxNumber: | 5038380994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HASP119476 | OR | X | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 231H00000X | 30205 | OR | X | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 229575 | 05 | OR | MEDICAID |