Provider Demographics
NPI:1114351376
Name:EVANS, KATIE R (DPM)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:R
Last Name:EVANS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:KATIE
Other - Middle Name:R
Other - Last Name:BERENDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:616 9TH ST N
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2320
Mailing Address - Country:US
Mailing Address - Phone:218-749-3818
Mailing Address - Fax:218-749-3874
Practice Address - Street 1:616 9TH ST N
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2320
Practice Address - Country:US
Practice Address - Phone:218-749-3818
Practice Address - Fax:218-749-3874
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN908213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1114351376Medicaid