Provider Demographics
NPI:1124422597
Name:EVAN, TERESA CLAIRE
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:CLAIRE
Last Name:EVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 W FIR ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-5703
Mailing Address - Country:US
Mailing Address - Phone:575-359-3820
Mailing Address - Fax:575-346-5948
Practice Address - Street 1:1515 W FIR ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-5703
Practice Address - Country:US
Practice Address - Phone:575-356-6695
Practice Address - Fax:575-356-5948
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126422363LF0000X
NM53252363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily