Provider Demographics
NPI:1316646821
Name:BAILON, EVAN ALFRED
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:ALFRED
Last Name:BAILON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W 234TH PL
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-5212
Mailing Address - Country:US
Mailing Address - Phone:310-613-4065
Mailing Address - Fax:
Practice Address - Street 1:3530 ATLANTIC AVE STE 108
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4569
Practice Address - Country:US
Practice Address - Phone:310-613-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant