Provider Demographics
NPI:1164035937
Name:EVANS, ALYSA JESICA (NP)
Entity Type:Individual
Prefix:
First Name:ALYSA
Middle Name:JESICA
Last Name:EVANS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-3915
Mailing Address - Country:US
Mailing Address - Phone:518-495-8429
Mailing Address - Fax:
Practice Address - Street 1:RIVERVIEW PEDIATRICS
Practice Address - Street 2:315 2ND AVE
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182
Practice Address - Country:US
Practice Address - Phone:518-235-6181
Practice Address - Fax:518-235-4323
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF383137-01363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics