Provider Demographics
NPI:1699590828
Name:BONCOLMO, EVAN CALLOS (RN)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:CALLOS
Last Name:BONCOLMO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 N KENDRICK AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1819
Mailing Address - Country:US
Mailing Address - Phone:615-753-1107
Mailing Address - Fax:
Practice Address - Street 1:806 N KENDRICK AVE
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1819
Practice Address - Country:US
Practice Address - Phone:161-575-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95312691163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse