Healthcare Provider Details

I. General information

NPI: 1003273947
Provider Name (Legal Business Name): SL EVANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 COUNTRY LAKE CIR
BOYNTON BEACH FL
33436-6200
US

IV. Provider business mailing address

32 COUNTRY LAKE CIR
BOYNTON BEACH FL
33436-6200
US

V. Phone/Fax

Practice location:
  • Phone: 561-213-9373
  • Fax: 561-423-2688
Mailing address:
  • Phone: 561-213-9373
  • Fax: 561-423-2688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9102141
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberARNP3280102
License Number StateFL

VIII. Authorized Official

Name: MR. LUCAS JAY EVANS
Title or Position: OWNER MANAGER
Credential: PA-C
Phone: 561-213-9373