Healthcare Provider Details

I. General information

NPI: 1073689766
Provider Name (Legal Business Name): CHARLES WAYNE EVANS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4704 HOEN AVE
SANTA ROSA CA
95405-7824
US

IV. Provider business mailing address

PO BOX 689 440 OAK STREET
PENNGROVE CA
94951-0689
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-7979
  • Fax:
Mailing address:
  • Phone: 707-795-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG46087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: