Healthcare Provider Details

I. General information

NPI: 1093007650
Provider Name (Legal Business Name): WENDY EVANS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 STAPLES MILL RD SUITE C
GLEN ALLEN VA
23060-3452
US

IV. Provider business mailing address

10150 STAPLES MILL RD SUITE C
GLEN ALLEN VA
23060-3452
US

V. Phone/Fax

Practice location:
  • Phone: 804-755-7581
  • Fax: 804-755-7586
Mailing address:
  • Phone: 804-755-7581
  • Fax: 804-755-7586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOT014122
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102203801
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: