Provider Demographics
NPI:1093833170
Name:EVANS, GREGORY T (DPM)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:T
Last Name:EVANS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:908 WYOMING AVE STE C
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-1300
Mailing Address - Country:US
Mailing Address - Phone:570-963-0535
Mailing Address - Fax:570-963-0534
Practice Address - Street 1:908 WYOMING AVE
Practice Address - Street 2:STE C
Practice Address - City:WYOMING
Practice Address - State:PA
Practice Address - Zip Code:18644-1300
Practice Address - Country:US
Practice Address - Phone:570-963-0535
Practice Address - Fax:570-963-0534
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASC003363L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232939043OtherTAX ID
PA001260793005Medicaid
PAU01401Medicare UPIN
PA473101Medicare PIN