Provider Demographics
NPI:1285617431
Name:EVANS, EVAN (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
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 1:1150 YOUNGS RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8024
Mailing Address - Country:US
Mailing Address - Phone:716-636-9004
Mailing Address - Fax:716-636-0132
Practice Address - Street 1:1150 YOUNGS RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8053
Practice Address - Country:US
Practice Address - Phone:716-636-9004
Practice Address - Fax:716-636-0132
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126194174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0598123Medicaid
NYC71281Medicare ID - Type Unspecified
NY0598123Medicaid