=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124048012
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN H CHRISTENSEN CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 02/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 GARNER FIELD RD
-----------------------------------------------------
City | UVALDE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78801-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-278-6251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 E LEONA RD
-----------------------------------------------------
City | UVALDE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78801-4866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-673-3072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 343983-4406
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 793080
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------