Provider Demographics
NPI:1972542272
Name:EVANS, MARK P (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:EVANS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10213 PARKER HILL RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NY
Mailing Address - Zip Code:14772-9744
Mailing Address - Country:US
Mailing Address - Phone:716-358-9729
Mailing Address - Fax:
Practice Address - Street 1:111 CLARA BARTON ST
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437
Practice Address - Country:US
Practice Address - Phone:585-335-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN356227L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP07250Medicare UPIN
PA038146Medicare ID - Type Unspecified