Healthcare Provider Details

I. General information

NPI: 1477384493
Provider Name (Legal Business Name): SCOTT BRUCE EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 BLUE LAKES BLVD N
TWIN FALLS ID
83301-3310
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 208-933-4442
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7681201
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: