Provider Demographics
NPI:1114332020
Name:EVELYN, VICTORIA M (PA)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:M
Last Name:EVELYN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:M
Other - Last Name:BOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4092 FOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-5225
Mailing Address - Country:US
Mailing Address - Phone:757-467-4200
Mailing Address - Fax:
Practice Address - Street 1:1755 48TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2712
Practice Address - Country:US
Practice Address - Phone:303-604-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004619363AM0700X
COPA.0008275363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical