Provider Demographics
NPI:1275052961
Name:EVANS, NICHOLAS BERTRAM (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BERTRAM
Last Name:EVANS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 558 BOX 4412
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96375-0045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 482
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362
Practice Address - Country:US
Practice Address - Phone:315-637-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program