Healthcare Provider Details

I. General information

NPI: 1104875475
Provider Name (Legal Business Name): CHARLIE EDWARD EVANS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 HOSPITAL DR
UKIAH CA
95482-4531
US

IV. Provider business mailing address

275 HOSPITAL DR
UKIAH CA
95482-4531
US

V. Phone/Fax

Practice location:
  • Phone: 707-462-7900
  • Fax: 707-462-7947
Mailing address:
  • Phone: 707-462-7900
  • Fax: 707-462-7947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG51002
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG51002
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: