Basic Information
| Provider Information | |||||||||
| NPI: | 1679519268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | ELLIS | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2550 N HOLLYWOOD WAY | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915051055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185570135 | ||||||||
| FaxNumber: | 8185571394 | ||||||||
| Practice Location | |||||||||
| Address1: | 869 NORTH CHERRY STREET | ||||||||
| Address2: | |||||||||
| City: | TULARE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932742287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596853450 | ||||||||
| FaxNumber: | 5596853869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 11/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA14524 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA14524 | 05 | CA | MEDICAID |