Provider Demographics
NPI:1083641260
Name:EVANS, STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:DO
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 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:1431 NURSERY ST STE 101
Practice Address - Street 2:
Practice Address - City:FOGELSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18051-1612
Practice Address - Country:US
Practice Address - Phone:610-336-8277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012305207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101872172Medicaid
PA106495Medicare PIN
H79578Medicare UPIN