1184715484 NPI number — MRS. LOANA EDITH EVANS N.P. - C

Table of content: MRS. LOANA EDITH EVANS N.P. - C (NPI 1184715484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184715484 NPI number — MRS. LOANA EDITH EVANS N.P. - C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
LOANA
Provider Middle Name:
EDITH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
N.P. - C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184715484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2115 S FREMONT AVE
Provider Second Line Business Mailing Address:
SUITE 4300
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-2239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-820-3911
Provider Business Mailing Address Fax Number:
417-820-3924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 S FREMONT AVE
Provider Second Line Business Practice Location Address:
SUITE 4300
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-2239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-820-3911
Provider Business Practice Location Address Fax Number:
417-820-3924
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN072421 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 431560263 . This is a "TRICARE WEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 242641702 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1184715484 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 176559758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00709666 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2221 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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