Healthcare Provider Details

I. General information

NPI: 1760517478
Provider Name (Legal Business Name): JONATHAN WALLACE EVANS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 06/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 NW SAMARITAN DR
CORVALLIS OR
97330-3737
US

IV. Provider business mailing address

444 NW ELKS DR
CORVALLIS OR
97330-3745
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-1276
  • Fax:
Mailing address:
  • Phone: 541-754-1276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101015261
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number43700
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: