Provider Demographics
NPI:1093007650
Name:EVANS, WENDY (DO)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10150 STAPLES MILL RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3452
Mailing Address - Country:US
Mailing Address - Phone:804-755-7581
Mailing Address - Fax:804-755-7586
Practice Address - Street 1:10150 STAPLES MILL RD
Practice Address - Street 2:SUITE C
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3452
Practice Address - Country:US
Practice Address - Phone:804-755-7581
Practice Address - Fax:804-755-7586
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014122208000000X
VA0102203801208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06115OtherGROUP PTAN