1407965155 NPI number — AMY EVANS

Table of content: AMY EVANS (NPI 1407965155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407965155 NPI number — AMY EVANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
AMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1407965155
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
887 E PORTSMOUTH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93720-0611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-434-8861
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W HERNDON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93612-0204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-432-4620
Provider Business Practice Location Address Fax Number:
559-324-6280
Provider Enumeration Date:
08/29/2006

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: 208000000X , with the licence number:  G86426 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00G864260 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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