Provider Demographics
NPI:1275707796
Name:EVANS, MICAH LEE (N/A)
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:LEE
Last Name:EVANS
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 TOGNINALI LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6029
Mailing Address - Country:US
Mailing Address - Phone:209-933-9010
Mailing Address - Fax:
Practice Address - Street 1:1610 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-5521
Practice Address - Country:US
Practice Address - Phone:209-943-0353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator