Healthcare Provider Details

I. General information

NPI: 1245763085
Provider Name (Legal Business Name): TREVOR JAMES EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2017
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 NEW MOODY LN
LA GRANGE KY
40031-9154
US

IV. Provider business mailing address

10007 SHINING WILLOW DR APT 102
LOUISVILLE KY
40241-3147
US

V. Phone/Fax

Practice location:
  • Phone: 502-222-5388
  • Fax:
Mailing address:
  • Phone: 801-979-2451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number132048
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1166968
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28237068A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: