Healthcare Provider Details

I. General information

NPI: 1083981260
Provider Name (Legal Business Name): DALLAS LAMAR EVANS ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2011
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6550 N WICKHAM RD SUITE 2
MELBOURNE FL
32940-2038
US

IV. Provider business mailing address

6742 RHODE ISLAND DRIVE WEST
JACKSONVILLE FL
32209-1436
US

V. Phone/Fax

Practice location:
  • Phone: 321-751-9506
  • Fax: 321-751-9505
Mailing address:
  • Phone: 904-380-0346
  • Fax: 904-768-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health
License NumberARNP9175957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: