Provider Demographics
NPI:1114245370
Name:EVANS, SARA JOSEPHINE (PA-C)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JOSEPHINE
Last Name:EVANS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:JOSEPHINE
Other - Last Name:MERRITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:140 AZURE MIST WAY
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-3701
Mailing Address - Country:US
Mailing Address - Phone:814-598-7920
Mailing Address - Fax:
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-426-4546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PAMA053442363AM0700X
FLPA9112233363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104059300Medicaid