Healthcare Provider Details

I. General information

NPI: 1346219029
Provider Name (Legal Business Name): MARY PALMQUIST EVANS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 ELM AVE
LOUISA VA
23093-6578
US

IV. Provider business mailing address

PO BOX 6126
CHARLOTTESVILLE VA
22901-6126
US

V. Phone/Fax

Practice location:
  • Phone: 434-242-7077
  • Fax:
Mailing address:
  • Phone: 434-242-7077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101233405
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: