Healthcare Provider Details

I. General information

NPI: 1093356255
Provider Name (Legal Business Name): PHILLIP MICHAEL EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 NORTHEAST EXPY NE STE 420
ATLANTA GA
30341-5304
US

IV. Provider business mailing address

3190 NORTHEAST EXPY NE STE 420
ATLANTA GA
30341-5304
US

V. Phone/Fax

Practice location:
  • Phone: 404-634-1111
  • Fax: 404-824-4142
Mailing address:
  • Phone: 404-634-1111
  • Fax: 404-824-4142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number060-R-0017
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: