Provider Demographics
NPI:1073587424
Name:GWILLIAM, EVAN MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:MICHAEL
Last Name:GWILLIAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7733 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-3862
Mailing Address - Country:US
Mailing Address - Phone:360-904-0205
Mailing Address - Fax:
Practice Address - Street 1:7733 GRANT ST
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-3862
Practice Address - Country:US
Practice Address - Phone:360-904-0205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7744544-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
844417000OtherBLUE CROSS
WAG8800402Medicare ID - Type Unspecified
U97972Medicare UPIN