Healthcare Provider Details

I. General information

NPI: 1679696611
Provider Name (Legal Business Name): ELLEN R EVANS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9662 N 29TH ST
OMAHA NE
68112-1524
US

IV. Provider business mailing address

9662 N 29TH ST
OMAHA NE
68112-1524
US

V. Phone/Fax

Practice location:
  • Phone: 402-510-9923
  • Fax:
Mailing address:
  • Phone: 402-510-9923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17202
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG5030
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14875
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number17202
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberG5030
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number14875
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: