Provider Demographics
NPI:1962525113
Name:NESBIT, EVADNA T (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:EVADNA
Middle Name:T
Last Name:NESBIT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12021 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1206
Mailing Address - Country:US
Mailing Address - Phone:866-968-6380
Mailing Address - Fax:866-986-6380
Practice Address - Street 1:12021 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1206
Practice Address - Country:US
Practice Address - Phone:866-968-6380
Practice Address - Fax:310-445-6622
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14380363A00000X
CA67564225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist