Provider Demographics
NPI:1083931711
Name:EVJEN, AMY NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:EVJEN
Suffix:
Gender:F
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 86370
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6370
Mailing Address - Country:US
Mailing Address - Phone:605-322-7510
Mailing Address - Fax:605-322-6475
Practice Address - Street 1:1325 S CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1007
Practice Address - Country:US
Practice Address - Phone:605-322-7905
Practice Address - Fax:605-322-8414
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57154207R00000X
390200000X
SD8820207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6008470Medicaid
SD6008470Medicaid