Provider Demographics
NPI:1083447676
Name:EVOLVE WELLNESS PROFESSIONAL CORP
Entity type:Organization
Organization Name:EVOLVE WELLNESS PROFESSIONAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:LORENZO ESCALONA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:702-969-4021
Mailing Address - Street 1:6859 S EASTERN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-0003
Mailing Address - Country:US
Mailing Address - Phone:702-356-2981
Mailing Address - Fax:702-356-2922
Practice Address - Street 1:6859 S EASTERN AVE STE 103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-0003
Practice Address - Country:US
Practice Address - Phone:702-356-2981
Practice Address - Fax:702-356-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-21
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250034589Medicaid