Provider Demographics
NPI:1255499398
Name:EVANS, LAURIE S (MD)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:S
Last Name:EVANS
Suffix:
Gender:F
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:STE 2047425 WRIGLEY DR. STE 204
Mailing Address - Street 2:7426 WRIGLEY DR. STE 204
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5292
Mailing Address - Country:US
Mailing Address - Phone:509-547-0027
Mailing Address - Fax:509-546-8386
Practice Address - Street 1:7425 WRIGLEY DR.
Practice Address - Street 2:STE 204
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5292
Practice Address - Country:US
Practice Address - Phone:509-547-0027
Practice Address - Fax:509-546-8386
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032005208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1100528Medicaid
IDP524103Medicaid
WAWAE319OtherQUALMED
020029975OtherMCR RR
WAEV2999OtherREGENCY
WA52019OtherLABOR AND INDUSTRIES
OR207464OtherOREGON WELFARE
52019OtherL AND I
WAG319000238Medicare ID - Type Unspecified
IDP524103Medicaid