MEDICARE: DR. EVONN LB O'NEILL M.D.

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
1	207Q00000X	Family Medicine Physician	MD00036446	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8906391	OTHER	WA	CRIME VICTIM COMPENSATION
3	0198643	OTHER	WA	WORKERS COMPENSATION

General Provider Information

NPI Number	:	1205887114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVONN LB O'NEILL M.D.

Provider Business Mailing Address
First Line	:	5952 BLACKSTONE WAY
Second Line	:
City	:	NINE MILE FALLS
State	:	WA
Zip	:	99026-4900
Country	:	US
Telephone Number	:	509-464-3627
Fax Number	:	509-466-9517

Provider Business Practice Location Address
First Line	:	5952 BLACKSTONE WAY
Second Line	:
City	:	NINE MILE FALLS
State	:	WA
Zip	:	99026-4900
Country	:	US
Telephone Number	:	509-464-3627
Fax Number	:	509-466-9517

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	05/09/2013

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