Healthcare Provider Details

I. General information

NPI: 1245476597
Provider Name (Legal Business Name): MATTHEW SHANE EVANS CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 COFFEE RD SUITE 1
MODESTO CA
95355-2809
US

IV. Provider business mailing address

1705 COFFEE RD SUITE1
MODESTO CA
95355-2809
US

V. Phone/Fax

Practice location:
  • Phone: 209-544-2273
  • Fax: 209-544-2274
Mailing address:
  • Phone: 209-544-2273
  • Fax: 209-544-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO02042
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO02042
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberCPO02042
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCPO02042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: