1366497604 NPI number — MS. DEBORAH A EVANS APRN,BC, FNP

Table of content: MS. DEBORAH A EVANS APRN,BC, FNP (NPI 1366497604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366497604 NPI number — MS. DEBORAH A EVANS APRN,BC, FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
DEBORAH
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN,BC, FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EVANS
Provider Other First Name:
DEBBIE
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366497604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 GARRETT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE GIRARDEAU
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63701-2741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-225-2442
Provider Business Mailing Address Fax Number:
573-339-7887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2441 MYRA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703-5803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-803-0919
Provider Business Practice Location Address Fax Number:
573-803-0879
Provider Enumeration Date:
05/24/2006

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: 363LA2200X , with the licence number:  121037 , 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: P00283737 . This is a "RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 429387509 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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