Healthcare Provider Details

I. General information

NPI: 1083454003
Provider Name (Legal Business Name): GAGE WARREN EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 RESEARCH RD SE
ALBUQUERQUE NM
87123-3423
US

IV. Provider business mailing address

4308 BOONE ST NE
ALBUQUERQUE NM
87109-2708
US

V. Phone/Fax

Practice location:
  • Phone: 575-347-8322
  • Fax:
Mailing address:
  • Phone: 575-347-8322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-2024-0090
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: