Healthcare Provider Details

I. General information

NPI: 1386522167
Provider Name (Legal Business Name): JACK A MCEVOY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 2ND AVE N
FORT DODGE IA
50501-4119
US

IV. Provider business mailing address

1428 2ND AVE N
FORT DODGE IA
50501-4119
US

V. Phone/Fax

Practice location:
  • Phone: 515-574-6110
  • Fax:
Mailing address:
  • Phone: 515-574-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number140767
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: