Provider Demographics
NPI:1235289216
Name:EVANS, THOMAS J (CRNA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:EVANS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 PROBST DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967
Mailing Address - Country:US
Mailing Address - Phone:631-281-3219
Mailing Address - Fax:631-395-9416
Practice Address - Street 1:1193 BEACH 9TH STREET
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691
Practice Address - Country:US
Practice Address - Phone:718-327-7078
Practice Address - Fax:718-471-3774
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2526391367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR0A07OtherBCBS
NYR0A07OtherBCBS