=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003273947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SL EVANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2016
-----------------------------------------------------
Last Update Date | 01/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 COUNTRY LAKE CIR
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33436-6200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-213-9373
-----------------------------------------------------
Fax | 561-423-2688
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 COUNTRY LAKE CIR
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33436-6200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-213-9373
-----------------------------------------------------
Fax | 561-423-2688
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER MANAGER
-----------------------------------------------------
Name | MR. LUCAS JAY EVANS
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 561-213-9373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | ARNP3280102
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA9102141
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------