Healthcare Provider Details

I. General information

NPI: 1275938615
Provider Name (Legal Business Name): MR. IAN EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 N. CREEK DR.
CONWAY AR
72032
US

IV. Provider business mailing address

PO BOX 679
MORRILTON AR
72110-0679
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-9788
  • Fax: 501-327-9843
Mailing address:
  • Phone: 501-354-4589
  • Fax: 501-354-5410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: