Healthcare Provider Details

I. General information

NPI: 1811260722
Provider Name (Legal Business Name): MARTHA F EVENCHIK PA-C, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 GARLAND ST
EVERETT MA
02149-5066
US

IV. Provider business mailing address

17 GRANITE ST
MELROSE MA
02176-5801
US

V. Phone/Fax

Practice location:
  • Phone: 617-389-6270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4363
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: