1366695439 NPI number — DR. MAYA CAPOOR EVANS MD

Table of content: LANCE H GRIGGS DDS (NPI 1124077128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366695439 NPI number — DR. MAYA CAPOOR EVANS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
MAYA
Provider Middle Name:
CAPOOR
Provider Name Prefix Text:
DR.
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:
CAPOOR
Provider Other First Name:
MAYA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366695439
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4860 Y ST
Provider Second Line Business Mailing Address:
SUITE 1700
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95817-2307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-734-7041
Provider Business Mailing Address Fax Number:
916-734-7838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4860 Y ST
Provider Second Line Business Practice Location Address:
SUITE 1700
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95817-2307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-734-7041
Provider Business Practice Location Address Fax Number:
916-734-7838
Provider Enumeration Date:
11/03/2008

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: 2081P0010X , with the licence number:  5545220 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 68086 0873 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1366695439 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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