Provider Demographics
NPI:1346219029
Name:EVANS, MARY PALMQUIST (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:PALMQUIST
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:PO BOX 6126
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-6126
Mailing Address - Country:US
Mailing Address - Phone:434-242-7077
Mailing Address - Fax:
Practice Address - Street 1:210 ELM AVE
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:VA
Practice Address - Zip Code:23093-6578
Practice Address - Country:US
Practice Address - Phone:434-242-7077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233405208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010155827Medicaid
F46742Medicare UPIN
00W257M01Medicare PIN
VA010155827Medicaid