Healthcare Provider Details

I. General information

NPI: 1952631988
Provider Name (Legal Business Name): MICHELLE LYNN EVANS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W HOSPITAL DR
WEST COLUMBIA SC
29169-3405
US

IV. Provider business mailing address

105 W HOSPITAL DR
WEST COLUMBIA SC
29169-3405
US

V. Phone/Fax

Practice location:
  • Phone: 803-796-2500
  • Fax: 803-796-4378
Mailing address:
  • Phone: 803-796-2500
  • Fax: 803-796-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1189
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: