Basic Information
| Provider Information | |||||||||
| NPI: | 1912901729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ALLAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8797 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049158797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103516500 | ||||||||
| FaxNumber: | 2103516509 | ||||||||
| Practice Location | |||||||||
| Address1: | 423 TREELINE PARK | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782092060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103516500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | E6774 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XX0005X | E6774 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | E6774 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P02601727 | 01 | TX | MCRR | OTHER | 128027307 | 05 | TX | MEDICAID |