Healthcare Provider Details

I. General information

NPI: 1710216569
Provider Name (Legal Business Name): MICHAEL DEAN EVANS DMSC, MPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

IV. Provider business mailing address

1636 REGULUS AVE
VIRGINIA BEACH VA
23461
US

V. Phone/Fax

Practice location:
  • Phone: 757-955-4047
  • Fax:
Mailing address:
  • Phone: 757-955-4047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: