Basic Information
| Provider Information | |||||||||
| NPI: | 1891790580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHARON | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3002 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142385 | ||||||||
| FaxNumber: | 3604142386 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 DELAWARE ST. | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986320302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142385 | ||||||||
| FaxNumber: | 3604142386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 01/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00044037 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0201114 | 01 | WA | LABOR & IND. | OTHER | 8435851 | 05 | WA | MEDICAID | 8913895 | 01 | WA | CRIME VICTIMS | OTHER | P00293336 | 01 | RR MEDICARE | OTHER | 270056 | 05 | OR | MEDICAID |