Healthcare Provider Details

I. General information

NPI: 1811942964
Provider Name (Legal Business Name): WILLIAM BRENT EVANS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 NO MAIN ST, STE201
TOOELE TN
84074
US

IV. Provider business mailing address

1244 NO MAIN ST, STE201
TOOELE TN
84074
US

V. Phone/Fax

Practice location:
  • Phone: 435-882-3968
  • Fax: 435-882-3859
Mailing address:
  • Phone: 435-882-3968
  • Fax: 435-882-3859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number274737-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: