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General NPI Number Information
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NPI Number | 1912043126
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Entity Type | Individual
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Provider Name | RICHARD BRUCE EVANS PA-C
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Gender | Male
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Dates
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Enumeration Date | 01/29/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 19401 HUBBARD DRIVE
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City | DEARBORN
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State | MI
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Zip | 48126
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Country | US
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Telephone | 313-982-8475
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Fax |
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Provider Business Mailing Address
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Address Line | 5554 E DARTMOOR DR
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City | MONROE
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State | MI
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Zip | 48161-5000
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Country | US
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Telephone | 734-457-2935
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 5601001293
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License Number State | MI
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