Provider Demographics
NPI:1083893218
Name:EVANGELISTI, MINDY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:
Last Name:EVANGELISTI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-2433
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-2433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00465500363A00000X
CO2470363AM0700X
PAMA059602363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87588820OtherMEDICAID GROUP NUMBER
COC810776OtherMEDICAID GROUP NUMBER
COC810212OtherMEDICARE GROUP NUMBER
CO50307711Medicaid
CO51858754OtherMEDICAID GROUP NUMBER
CO87588820OtherMEDICAID GROUP NUMBER
COCO303246Medicare PIN
CO50307711Medicaid