Provider Demographics
NPI:1184196784
Name:PHILLIPS, EVAN (PA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WINDCHASE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6546
Mailing Address - Country:US
Mailing Address - Phone:225-274-5148
Mailing Address - Fax:
Practice Address - Street 1:1103 KALISTE SALOOM RD STE 100&102
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5783
Practice Address - Country:US
Practice Address - Phone:225-274-5148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1O2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine