Provider Demographics
NPI:1073689766
Name:EVANS, CHARLES WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WAYNE
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:440 OAK STREET
Mailing Address - City:PENNGROVE
Mailing Address - State:CA
Mailing Address - Zip Code:94951-0689
Mailing Address - Country:US
Mailing Address - Phone:707-795-2175
Mailing Address - Fax:
Practice Address - Street 1:4704 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7824
Practice Address - Country:US
Practice Address - Phone:707-546-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46087207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G460870Medicaid
CAE48741Medicare UPIN
CA00G460870Medicare ID - Type Unspecified