Healthcare Provider Details

I. General information

NPI: 1316485006
Provider Name (Legal Business Name): EVAN M. CHALFIN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 MAIN STREET
FERNDALE CA
95536-1157
US

IV. Provider business mailing address

670 9TH ST STE 203
ARCATA CA
95521-6249
US

V. Phone/Fax

Practice location:
  • Phone: 707-786-4028
  • Fax: 707-786-9029
Mailing address:
  • Phone: 707-826-8633
  • Fax: 707-826-8638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201702103NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number341369
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95008874
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: