Provider Demographics
NPI:1174502603
Name:EVANS, JUSTIN P (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:P
Last Name:EVANS
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 1:3300 PROVIDENCE DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4671
Mailing Address - Country:US
Mailing Address - Phone:907-561-0005
Mailing Address - Fax:907-563-9140
Practice Address - Street 1:250 HOSPITAL PL
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-6999
Practice Address - Country:US
Practice Address - Phone:907-714-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46976207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN872956500Medicaid
MN050001761Medicare ID - Type Unspecified
MN872956500Medicaid