1952494122 NPI number — LISA SMITH EVANS MD

Table of content: ADEGBEMISOLA DANIYAN (NPI 1518351972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952494122 NPI number — LISA SMITH EVANS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
LISA
Provider Middle Name:
SMITH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1952494122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30337
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27130-0337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-718-8592
Provider Business Mailing Address Fax Number:
336-718-9269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 SILAS CREEK PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-3013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-718-5095
Provider Business Practice Location Address Fax Number:
336-718-9895
Provider Enumeration Date:
10/02/2006

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: 2085R0001X , with the licence number:  37824 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30913 . This is a "BLUECROSS/ BLUESHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7930913 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5860342 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 97951 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0194185006 . This is a "CIGNA HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2790 . This is a "PARTNERS NATIONAL HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2408400 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".




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