MEDICARE: EVERGREEN PRIMARY CARE PLLC

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
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1831768704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN PRIMARY CARE PLLC

Provider Business Mailing Address
First Line	:	1337 WILDERNESS RUN DR
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-1856
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1337 WILDERNESS RUN DR
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-1856
Country	:	US
Telephone Number	:	612-817-7240
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. SHARY VANG
Credential	:	MD
Telephone Number	:	612-817-7240

Provider Enumeration Date	:	06/23/2021
Last Update Date	:	06/23/2021

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