Provider Demographics
NPI:1285003772
Name:EVENSON, AMBER (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:EVENSON
Suffix:
Gender:F
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:BON HOMME FAMILY PRACTICE
Mailing Address - Street 2:410 W 16TH AVE
Mailing Address - City:TYNDALL
Mailing Address - State:SD
Mailing Address - Zip Code:57066-5209
Mailing Address - Country:US
Mailing Address - Phone:605-589-2190
Mailing Address - Fax:
Practice Address - Street 1:410 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:TYNDALL
Practice Address - State:SD
Practice Address - Zip Code:57066-2318
Practice Address - Country:US
Practice Address - Phone:605-589-2190
Practice Address - Fax:605-589-4603
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
SD1011363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD2010785Medicaid