Healthcare Provider Details

I. General information

NPI: 1326737172
Provider Name (Legal Business Name): EVON JOHN LOOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2113
  • Fax:
Mailing address:
  • Phone: 928-773-2113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number80610
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: