Provider Demographics
NPI:1063527471
Name:EVANS, JOSEPH MARK (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MARK
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11311 BRIDGEPORT WAY SW STE 205
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3051
Mailing Address - Country:US
Mailing Address - Phone:253-985-2733
Mailing Address - Fax:253-984-2049
Practice Address - Street 1:11311 BRIDGEPORT WAY SW STE 205
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3051
Practice Address - Country:US
Practice Address - Phone:253-985-2733
Practice Address - Fax:253-984-2049
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD606530272086S0102X, 208600000X
ORMD201102086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2002482Medicaid