Healthcare Provider Details

I. General information

NPI: 1518411982
Provider Name (Legal Business Name): COURTNEY MANION EVANGELISTA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MATTHEWS TOWNSHIP PKWY STE 110
MATTHEWS NC
28105-5403
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-3131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06539
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: