Healthcare Provider Details

I. General information

NPI: 1144223066
Provider Name (Legal Business Name): EVAN JOEL SWANSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S. MAIN ST.
OTTAWA KS
66067
US

IV. Provider business mailing address

PO BOX 460
OTTAWA KS
66067-0460
US

V. Phone/Fax

Practice location:
  • Phone: 785-229-8300
  • Fax: 785-229-8417
Mailing address:
  • Phone: 785-229-8284
  • Fax: 785-229-3377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0428397
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: