Provider Demographics
NPI:1093802621
Name:EVANS, REXFORD W (PA)
Entity Type:Individual
Prefix:MR
First Name:REXFORD
Middle Name:W
Last Name:EVANS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-261-5505
Mailing Address - Fax:315-261-6400
Practice Address - Street 1:80 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1450
Practice Address - Country:US
Practice Address - Phone:315-386-3300
Practice Address - Fax:315-261-6330
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY002857-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002857-1OtherLICENSE