Provider Demographics
NPI:1376908145
Name:BAILY, EVAN (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:BAILY
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 W PORTAL AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1305
Practice Address - Country:US
Practice Address - Phone:415-821-8798
Practice Address - Fax:415-242-6244
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031462363A00000X
CA58861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA059187OtherPENNSYLVANIA BOARD OF MEDICINE
PAOA004271OtherPENNSYLVANIA BOARD OF OSTEOPATHIC MEDICINE
DCCA1800038OtherCONTROLLED SUBSTANCE REGISTRATION
PAMB4553574OtherDEA LICENSE