Healthcare Provider Details

I. General information

NPI: 1396911830
Provider Name (Legal Business Name): N EVANS EINTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 N. MAIN
GRANITE OK
73547
US

IV. Provider business mailing address

417 NORTH MAIN P.O. BOX 243
GRANITE OK
73547-0243
US

V. Phone/Fax

Practice location:
  • Phone: 580-535-4598
  • Fax: 580-535-4725
Mailing address:
  • Phone: 580-535-4598
  • Fax: 580-535-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number802
License Number StateOK

VIII. Authorized Official

Name: NICOLE EVANS
Title or Position: PRESIDENT
Credential:
Phone: 580-706-0113