Healthcare Provider Details

I. General information

NPI: 1023518347
Provider Name (Legal Business Name): EVAN R WADSWORTH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 RIDGE RD
WASHINGTON IN
47501-8908
US

IV. Provider business mailing address

510 RIDGE RD
WASHINGTON IN
47501-8908
US

V. Phone/Fax

Practice location:
  • Phone: 812-698-7760
  • Fax:
Mailing address:
  • Phone: 812-698-7760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002428A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: