Basic Information
| Provider Information | |||||||||
| NPI: | 1841290798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 PROVIDENCE MINE RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | NEVADA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959592941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304708377 | ||||||||
| FaxNumber: | 5304708906 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 GLASSON WAY | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302746001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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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 | 207P00000X | A67869 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 208D00000X | A67869 | CA | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 00A678690 | 05 | CA | MEDICAID |