Provider Demographics
NPI:1083779052
Name:EVANS, BILLY ROYCE (PA)
Entity Type:Individual
Prefix:MR
First Name:BILLY
Middle Name:ROYCE
Last Name:EVANS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:343 SOUTH COMMERCIAL STREET
Mailing Address - Street 2:
Mailing Address - City:WELCH
Mailing Address - State:OK
Mailing Address - Zip Code:74369-0000
Mailing Address - Country:US
Mailing Address - Phone:918-788-3918
Mailing Address - Fax:918-788-3914
Practice Address - Street 1:343 SOUTH COMMERCIAL STREET
Practice Address - Street 2:
Practice Address - City:WELCH
Practice Address - State:OK
Practice Address - Zip Code:74369-0000
Practice Address - Country:US
Practice Address - Phone:918-788-3918
Practice Address - Fax:918-788-3914
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS46602Medicare UPIN