Healthcare Provider Details

I. General information

NPI: 1366616252
Provider Name (Legal Business Name): ELIZABETH D EVANS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 SEWALL ST
PORTLAND ME
04102-2643
US

IV. Provider business mailing address

51 SEWALL ST
PORTLAND ME
04102-2643
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-5761
  • Fax:
Mailing address:
  • Phone: 207-774-5761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-582
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: