Provider Demographics
NPI:1144223066
Name:SWANSON, EVAN JOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:JOEL
Last Name:SWANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-0460
Mailing Address - Country:US
Mailing Address - Phone:785-229-8284
Mailing Address - Fax:785-229-3377
Practice Address - Street 1:1301 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067
Practice Address - Country:US
Practice Address - Phone:785-229-8300
Practice Address - Fax:785-229-8417
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428397207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100397980BMedicaid
KS100397980AMedicaid
KS100397980BMedicaid
KS100397980AMedicaid
KS105636Medicare Oscar/Certification