Provider Demographics
NPI:1063410538
Name:EVANS, DAVID (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 SOUTHERN BLVD STE 2250
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1270
Mailing Address - Country:US
Mailing Address - Phone:937-534-0330
Mailing Address - Fax:937-522-8995
Practice Address - Street 1:3533 SOUTHERN BLVD STE 2250
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1270
Practice Address - Country:US
Practice Address - Phone:937-534-0330
Practice Address - Fax:937-522-8995
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000431363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0088798Medicaid
OHPA11432Medicare PIN