Provider Demographics
NPI:1528725546
Name:DEBOARD, EVAN BLAKE
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:BLAKE
Last Name:DEBOARD
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 1:329 GLEN ECHO LN APT D
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-9634
Mailing Address - Country:US
Mailing Address - Phone:423-416-0256
Mailing Address - Fax:
Practice Address - Street 1:4355 HICKORY BLVD STE 2
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:NC
Practice Address - Zip Code:28630-2014
Practice Address - Country:US
Practice Address - Phone:828-757-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCDEBO-F0JH8363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics