Healthcare Provider Details

I. General information

NPI: 1083386569
Provider Name (Legal Business Name): NICHOLAS ANATOLY EVANS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2021
Last Update Date: 10/02/2021
Certification Date: 10/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E ASH ST
PERRY FL
32347-2029
US

IV. Provider business mailing address

4000 SAINT JOHNS AVE APT 6201
JACKSONVILLE FL
32205-9487
US

V. Phone/Fax

Practice location:
  • Phone: 850-584-3278
  • Fax:
Mailing address:
  • Phone: 571-245-5358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9115061
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: