MEDICARE: MR. OSCEOLA M EVANS MSW

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	1041C0700X	Clinical Social Worker	C007664	NC
2	390200000X	Student in an Organized Health Care Education/Training Program

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1679803001	OTHER		DEPARTMENT OF DEFENSE

General Provider Information

NPI Number	:	1679803001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OSCEOLA M EVANS MSW

Provider Business Mailing Address
First Line	:	615 E HOUSTON ST STE 239
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78205-2001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 SCHOFIELD RD
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7577
Country	:	US
Telephone Number	:	210-808-2585
Fax Number	:

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

Provider Enumeration Date	:	01/07/2010
Last Update Date	:	03/17/2018

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