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NPI Code Detail

MEDICARE: EVOLVE WELLNESS PROFESSIONAL CORP

MEDICARE: EVOLVE WELLNESS PROFESSIONAL CORP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse Practitioner
2207Q00000XFamily Medicine Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1083447676
Entity Type Code : Organization
Provider Name (Legal Business Name) : EVOLVE WELLNESS PROFESSIONAL CORP
Provider Business Mailing Address
First Line : 6859 S EASTERN AVE STE 103
Second Line :
City : LAS VEGAS
State : NV
Zip : 89119-0003
Country : US
Telephone Number : 702-356-2981
Fax Number : 702-356-2922
Provider Business Practice Location Address
First Line : 6859 S EASTERN AVE STE 103
Second Line :
City : LAS VEGAS
State : NV
Zip : 89119-0003
Country : US
Telephone Number : 702-356-2981
Fax Number : 702-356-2922
Authorized Official
Title or Position : OWNER
Name : DARYL LORENZO ESCALONA
Credential : NP
Telephone Number : 702-969-4021
Provider Enumeration Date : 08/21/2024
Last Update Date : 03/25/2025

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Directions to “EVOLVE WELLNESS PROFESSIONAL CORP ” Practice Location

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