Healthcare Provider Details

I. General information

NPI: 1043486384
Provider Name (Legal Business Name): MATTHEW CRAIG EVANS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 N 300 W #201
PROVO UT
84604-6124
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2000
  • Fax:
Mailing address:
  • Phone: 801-356-0475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number6348954-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: