Healthcare Provider Details

I. General information

NPI: 1720095896
Provider Name (Legal Business Name): TIMOTHY J EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S ADAMS ST
FULTON MS
38843
US

IV. Provider business mailing address

3377 JOE WHEELER BROWN RD
FULTON MS
38843-7245
US

V. Phone/Fax

Practice location:
  • Phone: 662-862-4422
  • Fax: 662-862-4244
Mailing address:
  • Phone: 662-790-4902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR819687
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP09666
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR819687
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: